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FiSKE  Prize  Fund  Dissertation,  No.  XLII. 


THE  ETIOLOGY,  PATHOLOGY,  AND 
TREATMENT 


OF 


Diseases  of  the  Hip  Joint, 


ROBERT   W.   LOVETT,  M.D.,  ' 

OUT-PATIENT    SURGEON    TO   THE   BOSTON    CITY    HOSPITAL;     ASSISTANT    SURGEON 

TO    OUT-PATIENTS   AT   THE   CHILDREN'S    HOSPITAL,    BOSTON ;     MEMBER 

OF   THE   AMERICAN    ORTHOPEDIC   ASSOCIATION. 


"  I  knew  the  mass  of  men  conceal'd 
Their  thoughts,  for  fear  that  if  reveal'd, 
They  would  by  other  men  be  met 
With  blank  indifference,  or  with  blame  reproved." 

Matthew  Arnold,  "The  Buried  Life. ^'' 


BOSTON: 

Press  of  Geo.  H.  Ellis,  141   Franklin  Street. 

1891. 


THE  Trustees  of  the  Fiske  Fund,  at  the  annual  meetmg  of  the  Rhode  Island 
Medical  Society,  held  June  ii,  1891,  announced  that  they  had  awarded 
a  premium  of  three  hundred  dollars  for  the  best  essay  on  "  The  Etiology,  Pa- 
thology, and  Treatment  of  Diseases  of  the  Hip  Joint "  to  an  essay  bearing  the 
motto, — 

"  I  knew  the  mass  of  men  conceal'd 
Their  thoughts,  for  fear  that  if  reveal 'd. 
They  would  by  other  men  be  met 
With  blank  indifference,  or  with  blarae  reproved." 

The  author  was  found  to  be  Dr.  Robert  W.  Lovett,  of  Boston,  Mass. 

WILLIAM  H.  PALMER,  M.D.,  Providence, 
ROBERT  F.  NOYES,  M.D.,  Providence, 
ELISHA  P.  CLARKE,  M.D.,  Hop  Valley, 

Tricstees. 
GEORGE  L.  COLLINS,  M.D.,  Providence, 

Secretary  of  the  Trustees. 


CONTENTS. 


PACE. 

I.     Introduction  and  Classification           9 

II.    Acute  Arthritis 14 

III.  Acute  Synovitis 27 

IV.  Chronic  Serous  Synovitis 39 

V.  Tuberculous  Ostitis  (Hip  Disease):  Pathology  and 

Etiology,  including  Chronic  Purulent  Synovitis  ...  44 

VI.  Tuberculous  Ostitis  (Hip  Disease):  Treatment  .     .  70 

VII.     Gummatous  Ostitis 145 

VIII.    Arthritis  Deformans 148 

IX.     Charcot's  Disease 166 

X.    Malignant  and  Other  Tumors 171 

XI.     Loose  Bodies 179 

XII.     Congenital  Dislocation ,    .     .  182 

XIII.     Hysterical  Affections       215 


Chapter  I. 
INTRODUCTION    AND    CLASSIFICATION. 

In  the  present  state  of  Pathology  it  is  impossible  to  present 
any  classification  of  diseases  of  the  hip  joint  which  shall 
be  exact,  or  which  shall  be  sanctioned  by  authority  weighty 
enough  to  give  it  pre-eminence.  It  is  essentially  a  time  of 
transition  in  the  history  of  the  pathology  of  bone  and  joint 
disease,  a  time  when  tuberculosis  has  sprung  into  such 
prominence  that  the  tendency  is  to  refer  to  it  the  great 
mass  of  all  chronic  bone  and  joint  disease.  Coming  as  it 
did  upon  a  pathology  in  which  tuberculosis  played  a  minor 
part,  this  change  has  disturbed  the  former  arrangement;  and 
enough  time  has  not  yet  elapsed  for  the  evolution  of  a  new 
and  permanent  basis  of  classification.  Consequently,  each 
one  who  deals  with  these  subjects  has  to  formulate  for  him- 
self, as  best  he  can  under  the  existing  conditions,  the  phe- 
nomena occurring  in  diseased  joints. 

The  classification  given  here  is  merely  a  scheme  of  abnor- 
mal conditions,  which  are  to  be  clearly  recognized  in  the  hip 
joint,  and  which,  it  is  hoped,  has  at  least  the  merit  of  being 
practical.  It  follows  no  authority,  because  there  is  none  to 
follow ;  and  it  must  stand  on  its  own  merits  as  a  practical 
working  classification.  It  does  not  enter  into  the  refine- 
ments of  subdivision,  and  so  far  as  is  practicable  it  rests 
upon  a  pathological  basis.  It  has  not  been  possible,  for 
obvious  reasons,  to  follow  this  out  rigidly  ;  but,  so  far  as 
possible,  a  pathological  rather  than  an  etiological  basis  has 
been  adopted. 


10  DISEASES    OF    THE    HIP   JOINT 

Acute  Diseases  of  the  Hip  Joint. 
Acute  Arthritis. 

«      ,     e  •*•     (  Serous. 

Acute  Synovitis.  ^  ^^       ,      . 
{  Purulent. 

Chronic  Diseases  of  the  Hip  Joint. 

^,        .     c  •<-•      *^  Serous. 

Chronic  Synovitis.-  -p,       i     ^« 
(  Purulent.* 

Chronic  Ostitis  (Tubercular). 

Chronic  Ostitis  (Gummatous). 

Arthritis  Deformans. 

Charcot's  Disease. 

Malignant  and  other  Tumors. 

Loose  Bodies. 

Miscellaneous  Conditions. 

Congenital  Dislocations. 

Functional  Affections. 

*  Chronic  purulent  synovitis  is  considered  together  with  chronic  ostitis. 

The  discussion  of  the  subject  has  been  confined  strictly 
and  entirely  to  the  subjects  of  Pathology,  Etiology,  and 
Treatment,  as  prescribed  by  the  Trustees  of  the  Fiske  Fund. 
Each  affection  has  been  considered  separately,  and  the  pa- 
thology, etiology,  and  treatment  of  each  are  discussed  individ- 
ually in  the  order  designated.  Inasmuch  as  in  so  extensive 
a  subject  as  this  it  is  manifestly  impracticable  to  treat  all 
parts  with  equal  thoroughness,  it  has  been  the  aim  of  the 
writer,  so  far  as  possible,  to  present  the  more  practical  side 
of  the  question,  and  to  lay  particular  stress  upon  the  dis- 
cussion of  the  treatment  of  the  various  affections,  and  par- 
ticularly the  treatment  of  that  most  common  of  all  affections 
of  the  hip  described  under  the  name  of  hip  disease.  Where 
it  has  been  possible,  the  writer  has  endeavored  to  give  the 
scientific  reasons  for  the  different  modes  of  treatment.  The 
consideration  of  the  pathology  and  etiology  was  of  necessity 
of  the  nature  of  a  compilation  ;  but,  in  discussing  the  treat- 
ment of  the  various  affections,  it  has  been  the  aim  of  the 
writer  to  make  it,  to  a  certain  extent,  individual,  by  giving 


INTRODUCTION    AND    CLASSIFICATION  II 

the  results  of  his  own  experience  in  addition  to  that  of  other 
authors.  It  was  a  question  in  the  mind  of  the  writer  whether 
congenital  dislocation  of  the  hip  should  be  considered  in  this 
connection.  It  seems,  however,  that  any  consideration  of 
diseases  of  the  hip  would  sadly  lack  completeness  that  failed 
to  include  so  important  and  so  comparatively  common  a 
condition  as  this,  and  on  this  ground  that  deformity  has 
been  placed  upon  an  equal  footing  with  the  other  conditions. 

A  few  words  should  be  said  with  regard  to  the  anatomical 
relations  of  the  hip  joint.  The  joint  lies  so  deeply  buried 
in  the  soft  parts  that  it  possesses  a  remoteness  that  is  not  a 
condition  in  any  other  joint.  As  a  result  of  this,  in  hip  joint 
inflammations  the  seat  of  the  disease  itself  is  not  accessi- 
ble to  examination  and  observation,  as  is  the  case  in  the 
more  exposed  joints.  One  must  depend  more  upon  the  re- 
mote symptoms,  such  as  muscular  spasm  and  the  various 
malpositions,  than  on  the  direct  evidences  furnished  by  pal- 
pation and  direct  examination  of  the  hip  joint  cavity. 

This  adds  an  unfortunate  complication  to  .the  study  of 
diseases  of  the  hip,  because  nowhere  is  the  early  diagnosis 
more  important  than  here,  and  nowhere  are  the  disastrous 
results  of  overlooking  the  disease  more  distressing.  On 
account  of  its  remoteness  and  its  firm  protection  by  the 
strongest  muscles  and  ligaments  of  the  body,  the  joint  is 
not  one  which  is  liable  to  traumatic  affections,  as  any  force 
exerted  upon  the  leg  is  more  likely  to  find  its  expression  in 
traumatic  inflammation  of  the  less  protected  knee  and  ankle. 

The  development  of  the  femur  is  by  one  centre  of  ossifi- 
cation for  the  shaft,  and  one  for  each  of  the  four  epiphyses. 
A  single  centre  for  the  lower  epiphysis  appears  shortly  be- 
fore birth,  one  for  the  head  of  the  femur  in  the  first  year, 
one  for  the  great  trochanter  in  the  fourth  year,  and  one  for 
the  trochanter  minor  in  the  thirteenth  or  fourteenth  year. 
A  neck  is  formed  by  extension  of  the  ossification  from  the 
shaft,  and  the  head  is  not  united  to  the  shaft  by  bony  union 
until  the  eighteenth  or  nineteenth  year.     The  physiological 


12  DISEASES    OF    THE    HIP   JOINT 

development  is  most  rapid  and  most  marked  in  the  upper 
epiphysis,  and  especially  in  the  neighborhood  of  the  epiphys- 
eal cartilage. 

Certain  points  are  of  practical  interest  as  considered  in 
Mr.  Morris's  "Anatomy  of  the  Joints." 

1.  The  head  of  the  bone  is  completely  included  in  the 
acetabulum. 

2.  The  whole  upper  epiphysis  of  the  femur  is  within  the 
joint. 

3.  The  direction  of  the  axis  of  the  neck  of  the  bone  is 
such  that  a  force  applied  to  the  trochanter  will  tend  to  oblit- 
erate the  angle  between  the  neck  and  the  shaft  of  the  bone, 
and  consequently  will  be  largely  expended  upon  the  inner 
aspect  of  the  neck. 

4.  The  main  vessels  of  supply  to  the  bone  enter  upon  the 
upper  surface  of  the  neck. 

5.  The  fact  that  the  nerve  supply  is  derived  from  the  an- 
terior crural,  the  obturator,  and  accessory  obturator  nerves, 
along  with  the  sacral  plexus,  and  that  these  are  to  a  large 
extent  the  same  nerves  which  supply  the  important  muscles 
controlling  the  hip  joint. 

6.  That  the  psoas  bursa  frequently  communicates  with  the 
joint  through  the  thin  triangular  space  between  the  ilio- 
pectineo-femoral  band. 

7.  The  cartilage  covering  the  head  of  the  femur  is  not  all 
articular,  in  the  sense  that  it  forms  a  part  of  the  bearing 
surface  of  the  joint.  A  considerable  zone,  which  may  be 
designated  "marginal,"  extends  around  the  rest,  and  is  more 
or  less  provided  with  synovial  membrane.  This  cartilage 
often  persists  after  destruction  of  the  articular  surface,  and 
through  this  zone  numerous  vessels  pass,  which  in  disease 
are  often  enlarged.  These  vessels  are  apparently  derived 
from  synovial  membrane  ;  and  in  most  cases,  no  doubt,  in- 
flammation reaches  the  synovial  tissue  through  their  agency. 

8.  The  ligamentum  teres  forms,  as  it  were,  a  channel 
through  the  articular  cartilage  to  the  bone, —  a  fact  of  impor- 


INTRODUCTION    AND    CLASSIFICATION  1 3 

tance  in  determining  the  extension  of  disease  from  the  bone 
into  the  joint. 

9.  The  normal  range  of  movement  of  the  joint  is  through 
145-150  degrees. 

Flexion  is  checked  by  contact  of  the  thigh  with  the  abdo- 
men and  hyper-extension  by  the  Y-ligament. 

Finally,  it  is  important  once  more  to  call  attention  to  the 
very  active  physiological  hyperaemia  which  exists  in  the 
neighborhood  of  the  epiphyseal  cartilage,  and  which  is  an 
important  factor  in  determining  the  location  of  tuberculosis 
ostitis. 


14  DISEASES    OF    THE    HIP    JUlXT 


Chapter  II. 
ACUTE   ARTHRITIS   OF   THE   HIP  JOINT. 

BEING   A    FORM   OF   THE  ACUTE   ARTHRITIS 
OF   INFANTS. 

The  affection  has  also  been  described  as  Pcraciite  Articu- 
lar Ostitis,  or  Epiphysitis  (Barwell  and  Stromeyer  *),  Acute 
Epiphysitis  and  Suppurative  Ostitis  (MacNamara  f),  Meniugo- 
osteo-pJdebitis  and  EpipJiysentrennuug  (Klose  |),  Acute  Osteo- 
myelitis and  Necrosis  of  Epiphyses  (Jones  §). 

Earlier  writers  describe  what  appears  to  have  been  this 
affection  under  a  multiplicity  of  names,  which  it  seems  of 
little  use  to  catalogue.  A  complete  list  of  them  is  given  in 
Townsend's  article  upon  the  subject. || 

The  many  different  names  applied  to  this  condition  point 
to  an  obscure  pathological  process,  which  is  differently  in- 
terpreted. Later  usage  has  adopted  the  "name  of  Acute 
Arthritis  of  Infants  for  the  particular  condition  under  dis- 
cussion, which  describes  accurately  enough  the  disease,  and 
does  not  postulate  any  definite  pathological  theory.  The 
term  was  first  used  byTerisse^  in  an  inaugural  thesis  in 
1833  ;  but  its  present  use  is  due  to  the  classical  article  of  Mr. 
Thomas  Smith  in  1874,  which  was  the  first  clear  description 
of  the  affection  and  from  which  dates  its  modern  recogni- 
tion.** 

*  Diseases  of  Joints.     R.  Barwell.     Americaa  Ed.     1881. 

t  Diseases  of  the  Bones  and  Joints.     MacNamara.     London,  1SS7. 

$  Prager  Vierteljahrschaft.     1S5S. 

§  Diseases  of  the  Bones.     Thomas  Jones.     London,  1887. 

II  Acute  Arthritis  of  Infants,  American  Journal  of  Medical  Sciences.  Januars*,  1S90. 

IT  Observations  d'Arthrites  aigues  chez  r  Enfant  nouveau  ne.     Paris. 

**St.  Barth.  Hosp.  Rep.  1874,  vol.  x. 


acute  arthritis  of  the  hip  joint  1 5 

Pathology. 

It  is  not  probable  that  the  term  acute  arthritis  of  infants 
represents  any  pathological  entity,  as  was  first  considered 
to  be  the  case  by  those  who  described  it.  Rather  it  is  to 
be  considered  as  an  acute  joint  destruction,  in  most  cases 
pyemic,  but  also  to  be  attributed  to  other  causes.  Clinically, 
all  these  cases  are  described  as  acute  arthritis  of  infants. 

Pathologically,  this  affection  may  be  the  result  of  (i)  a 
syphilitic  osteo-chondritis,  (2)  a  catarrhal  synovitis  passing  on 
to  ostitis,  (3)  a  tuberculous  ostitis  running  a  rapid  course, 
(4)  a  juxta-epiphyseal  osteomyelitis  of  a  septic  character. 

The  first  three  divisions  will  be  described  under  their  ap- 
propriate headings  in  other  parts  of  the  essay,  and  here  will 
be  considered  only  the  last  named,  originally  supposed  to  be 
the  sole  condition  found  in  acute  arthritis,  and  which  consti- 
tutes the  bulk  of  all  cases  of  arthritis  of  the  hip  occurring  in 
children  less  than  a  year  old. 

Acute  arthritis  of  infants  in  most  cases  is,  then,  an  acute 
infectious  osteomyelitis  of  the  upper  epiphysis  of  the  femur. 

This  was  the  view  of  Mr.  Smith  in  his  original  article,  and 
later  investigations  have  borne  out  this  idea. 

In  most  cases,  therefore,  the  disease  is  to  be  considered 
as  an  affection  primarily  osseous.  The  great  formative  ac- 
tivity which  exists  at  the  upper  epiphyseal  cartilage  of  the 
femur  in  the  early  years  of  life  is  an  explanation  of  many  of 
the  phenomena  of  this  disease. 

Bone  disease  of  all  sorts  is  more  likely  to  originate  on 
the  diaphyseal  side  of  the  epiphyseal  cartilage  than  on  the 
articular  side.  Fourteen-fifteenths  of  the  length  of  the  bone 
are  due  to  the  growth  on  this  diaphyseal  side,  if  we  may 
accept  Ollier's  estimate  ;  and  this  great  formative  activity,  of 
course,  means  a  state  of  physiological  congestion.  On  the 
diaphyseal  side  of  the  cartilage  one  finds  a  dense  capillary 
network,  surrounded  by  a  venous  plexus  ;  a  spongy  tissue,  in 
short,  predisposed  by  its  structure  and  its  function  to  acute 


l6  DISEASES    OF    THE    HIP    JOINT 

congestion,  venous  stasis,  and  rapid  disintegration  Moreover, 
it  is  easy  to  see,  as  ]\Ir.  Neve  *  explains,  why  external  causes 
tend  to  locate  disease  of  the  bone  in  this  region.  When  a 
child  is  exposed  to  a  sudden  jar  or  a  traumatism  of  any 
sort,  much  of  the  force  will  be  transmitted  to  the  cartilage 
and  modified  by  its  elasticity.  But  the  maximum  effect  of 
the  injury  will  be  manifested,  for  mechanical  reasons,  at 
the   junction   of   the    rigid   bone  and  yielding  cartilage. 

[Moreover,  the  fine  capillary  network  above  alluded  to  will 
act  as  a  filter  for  infectious  material  and  pathogenic  or- 
ganisms. 

For  these  reasons  infection  and  traumatism  in  predisposed 
subjects  favor  a  juxta-epiphyseal  location  of  the  disease,  and 
this  explanation  serves  equally  well  to  explain  why  chronic 
articular  ostitis  is  located  so  often  in  the  same  region. 

The  first  stage  of  the  process  is  an  increased  hypersemia 
of  the  vessels  in  the  neighborhood  of  the  epiphyseal  cartilage. 
Stasis  and  cellular  infiltration  follow,  and  with  the  distention 
of  the  vessels  the  nutritive  supply  is  cut  off  over  large  or 
small  areas,  because  swelling  is  impossible  on  account  of  the 
rigid  cortical  layer,  and  strangulation  follows,  causing  the 
necrosis  of  larger  or  smaller  areas  of  spongy  tissue. 

An  acute  purulent  inflammation  being  present  under  such 
conditions,  the  destruction  of  bone  is  rapid.  Melted  down 
by  the  pus  or  shut  off  from  its  blood  supply,  it  disintegrates, 
and  the  process  extends,  most  often  in  the  direction  of  the 
joint. 

At  an  early  stage  the  naked  eye  sees  on  section  an  area 
of  spongy  tissue  of  considerable  extent,  which  is  bright  red 
or  dusky;  and  the  marrow  is  transformed  into  a  semi-fluid 
mass  of  pus  and  melted  fat,  often  offensive  in  odor,  colored 
more  or  less  red  b}'  extravasated  blood.  The  periosteum  is 
generally  thickened,  and  purulent  periostitis  may  be  present 
secondarily.  The  cancellous  tissue  is  pink  and  somewhat 
thickened.     If  the  detritus  is  washed  away,  the  spongy  tissue 

♦Arthur  Xeve,  Practitioner,  January,  iSgi. 


ACUTE    ARTHRITIS    OF    THE    HIP    JOINT  IJ 

appears  red  and  softened,  with,  perhaps,  spots  of  disintegra- 
tion or  bits  of  necrosis.  In  some  cases,  the  necrosis  may 
have  been  sufficient  to  show  a  sequestrum  of  considerable 
size.  At  times  the  pus  may  be  dark  and  thin,  or  it  may  be 
profuse,  and  resemble  laudable  pus. 

In  most  cases,  the  process  tends  to  involve  the  joint. 
Commonly,  the  inflammation  extends  by  the  spongy  tissue  to 
the  articular  surface,  and  destroys  the  cartilage  over  a  larger 
or  smaller  area,  entering  the  joint  to  start  up  an  acute  puru- 
lent synovitis.  In  other  instances,  it  may  burrow  under  the 
periosteum,  having  started  as  a  subperiosteal  abscess  at  some 
more  remote  point,  and  enter  the  joint  in  that  way.  In  still 
rarer  instances,  it  may  seek  the  surface  of  the  bone,  and,  dis- 
charging into  the  soft  parts,  come  to  the  surface  and  be 
evacuated  without  infecting  the  joint. 

The  relations  of  the  epiphysis  and  the  joint  capsule  in 
young  children  are  such  that  a  focus  of  disease  beginning  in 
the  epiphysis  is  practically  within  the  joint  from  the  begin- 
ning, as  the  epiphyseal  cartilage  is  indistinguishable  from 
the  articular  cartilage,  and  is  in  immediate  relation  with  the 
capsule  of  the  joint. 

When  the  joint  is  infected,  destruction  is  rapid.  The  carti- 
lages and  the  articular  ends  of  the  bones  melt  down  into  pus, 
the  capsule  bursts,  and,  if  the  process  continues,  the  ligaments 
and  the  capsule  melt  away.  Sinuses  form  to  drain  away  the 
products  of  destruction,  and  it  seems  difficult  to  set  a  limit 
to  the  process. 

The  destruction  about  the  epiphyseal  cartilage  may  be  so 
much  that  it  is  loosened  from  the  diaphysis  and  lies  loose,  as 
if  a  section  of  the  neck  of  the  femur  had  been  made.  This 
results  in  a  flail-like  joint,  and  simulates  very  closely  in  walk- 
ing and  manipulation  the  condition  known  as  congenital 
dislocation  of  the  hip.  This  is  a  common  ending  in  cases  of 
acute  arthritis  which  recover. 

In  other  cases,  an  extensive  sequestrum  may  remain.  In 
young  children  however,  the  usual  victims  of  this  affection, 


1 8  DISEASES    OF    THE    HIP    JOINT 

the  process  is  of  such  virulence  that  necrosis  is  of  little 
account  compared  with  the  rapid  and  extensive  destruction 
of  the  bone  and  soft  parts  and  the  general  sepsis,  which  is 
most  marked. 

The  character  of  pyogenic  germs  in  the  pus  of  acute  ar- 
thritis is  a  matter  of  much  interest.  In  the  pus  one  finds 
various  forms  of  the  staphylococci,  notably  the  S.  aureus. 
Exceptionally,  the  streptococci  may  be  present  as  the  cause 
of  suppuration  ;  and  Volkmann  found  a  coccus  resembling 
the  diphtheritic  coccus  of  Loeffler. 

Metastatic  abscesses  may  be  found  present,  and  the  other 
pathological  signs  of  general  pyasmia  are  common  in  the 
cases  of  longer  duration. 

In  cases  which  have  successfully  withstood  the  acute  at- 
tack of  the  disease,  several  conditions  may  be  found  which 
speak  for  the  virulence  and  destructiveness  of  the  affection. 
As  has  been  said,  (i)  the  epiphysis  may  be  separated  from 
the  femur  and  a  fiail-like  joint  be  the  result,  (2)  the  head 
of  the  femur  may  be  so  eroded  and  the  capsule  so  disinte- 
grated that  dislocation  may  have  occurred,  (3)  the  articu- 
lar ends  of  the  bone  may  be  roughened  and  destitute  of  car- 
tilage, so  that  joint  movement  is  accompanied  by  grating,  (4) 
or,  finally,  more  or  less  complete  fibrous  or  bony  anchylosis 
may  be  present ;  but  this  is  not  so  common  as  the  other  ter- 
minations. 

Etiology. 

The  etiology  of  this  form  of  joint  disease  is  obscure;  and, 
in  the -present  state  of  knowledge  regarding  it,  the  question 
can  only  be  briefly  discussed,  and  dismissed  as  unsettled. 
The  pathological  knowledge  is  imperfect,  as  it  must  have 
already  appeared,  largely  because  the  data  are  insufficient, 
and,  from  the  etiological  side,  the  data  are  even  more  unsatis- 
factory. 

Traumatism  is,  of  course,  assigned  a  place  in  the  etiology, 
and  certain  cases  seem  clearly  traumatic  in  origin,  as  in  one 


ACUTE    ARTHRITIS    OF    THE    HIP   JOINT  IQ 

of  Mr.  Smith's  cases,  where  rough  handling  at  birth  seemed 
to  have  been  the  cause  of  the  subsequent  joint  trouble.  But 
for  a  simple  traumatism  to  cause  so  violent  and  destructive 
a  process  seems  unlikely  and  not  reasonable. 

Rosenbach  *  demonstrated  by  experiments  upon  animals 
that  neither  mechanical  injuries  nor  comminution  of  the  mar- 
row by  violence  were  sufficient  to  cause  suppuration  at  the 
seat  of  injury.  He  showed,  further,  that  the  marrow  was  ex- 
tremely sensitive  to  the  influence  of  septic  substances,  such 
as  rancid  butter,  or  the  products  of  decomposition  in  general. 
Krause'sf  experiments  form  a  very  interesting  complement 
to  these.  He  showed  that  in  animals  who  had  been  infected 
by  the  injection  of  6".  auretis  and  albus  cultivated  from  osteo- 
myelitic  pus  the  fracture  of  the  bones  was  followed  by  sup- 
puration at  the  seat  of  the  injury,  which  was  like  an  ordinary 
septic  infection  occurring  there,  except  that  the  marrow  was 
more  extensively  involved. 

These  experiments  would  lead  one  to  infer  that  traumatism 
alone  was  not  enough  to  cause  so  great  a  destruction  as  oc- 
curs in  these  cases,  but  that,  in  connection  with  infection, 
either  general  or  local,  it  might  serve  as  the  exciting  and  de- 
termining cause  of  the  affection.  Such  a  state  of  affairs  is 
quite  parallel  to  what  will  be  observed  later  in  speaking  of 
the  etiology  of  tuberculous  disease. 

Pure  cultivations  have  been  made  from  the  cocci  of  acute 
osteomyelitis, J  and,  as  has  been  said,  it  was  found  that,  if 
they  were  injected  into  the  blood,  bone  injuries  and  fract- 
ures suppurated. §  By  their  injection  into  joints,  purulent 
arthritis  was  started  up,  and  great  quantities  in  the  circula- 
tion killed  rabbits  and  guinea  pigs.  Rosenbach  found  the 
same  coccus  in  furuncles,  empyaema,  abscesses,  and  pyaemia. 

The  place  of   traumatism,  then,  in  the  etiology  becomes- 

*Cent.  f.  Chir.,  1S84,  No.  5;  1877,  p.  289. 

t  Fortsch.   der  Medicin,  1884,  Nos.  7  and  8 

+  Rosenbach,  Mikro-organismen  b.  d.  Wundinfectionskrank.    Wiesbaden,  1884.. 

§  Krause,  Fortsch.  der  Med.,  ii.      1884. 


20  DISEASES    OF    THE    HIP    JOINT 

subordinate  to  that  of  infection  of  the  general  system  from 
some  source.  An  injury  may  be  enough  to  locate  a  de- 
structive process  in  some  one  joint,  or,  on  the  other  hand,  so 
far  as  can  be  told,  the  disease  may  originate  without  trauma. 

The  obscure  question  arises,  when  one  asks,  Why  children 
under  one  year  are  the  ones  particularly  liable  to  this  affec 
tion,  and  how  do  apparently  healthy  children  become  sud- 
denly infected,  and  by  what  channels  ? 

In  this  connection  the  statement  of  Escherich  is  of  particu- 
lar interest,  who  found  in  all  children  at  the  breast,  whether 
well  or  ill,  the  Staphylococcus  aureus  and  albiis  in  the  liver 
and  the  superficial  layers  of  the  skin. 

In  the  acute  infectious  diseases,  pyemic  affections  are 
not  uncommon,  and  acute  destructive  joint  disease  occurs 
in  older  and  in  vounger  children.  The  acute  arthritis  of 
infants  is  one  of  the  forms  of  this  manifestation,  and  the 
pyemic  infection  after  the  exanthemata  is  one  of  the  most 
common  and  the  most  satisfactory  of  explanations  for  the 
presence  of  the  pathogenic  germs  in  this  disease.  Of  a 
comparatively  small  number  (about  75)  of  these  cases  on 
record,  a  larger  proportion  are  to  be  traced  to  the  exan- 
themata than  to  any  one  cause. 

Cases  have  been  reported  due  to  chicken-pox,*  and  to  va- 
riola,! measles,  and  scarlatina,t  and,  finally,  pertussis, §  and 
typhoid  fever.  The  definite  etiological  character  of  the  joint 
affections  following  the  exanthemata  has  not  been  formulated 
further  than  to  class  them  as  pyemic.  The  frequency  of 
such  affections  requires  no  comment. 

As  an  instance  of  a  direct  source  for  purulent  infection 
may  be  mentioned  cases  of  suppurating  umbilicus.  Such 
cases  came  under  the  observation  of  Townsend.  In  one 
case,  empyasma  seemed  to   be  the  cause.     Again,  a  wound 

*  Holmes,  Surg.  Treat,  of  Dis.  of  Inf.  and  Childhood. 

tMcLeod,  Indian  Med.  Gazette,  1SS3,  p.  232;  Ancell,  Archives  of  Medicine.  1S30,  vol.  iv. 
p.  491. 

{Eustace  Smith  and  Ashby  and  Wright,  in  their  Diseases  of  Children. 
§  Ashb}-  and  Wright,  Diseases  of  Children. 


ACUTE    ARTHRITIS    OF    THE    HIP    JOINT  21 

may  appear  to  be  the  site  of  the  infection ;  but,  in  most 
cases,  one  must  fall  back  necessarily  upon  a  theoretical  ex- 
planation of  the  entrance  of  the  germs,  and  assume  "that 
the  infection  may  occur  through  the  ears,  eyes,  nose,  mouth, 
pharynx,  respiratory  passages,  mucosa  of  the  alimentary 
canal,  or  skin  ;  .  .  .  furthermore,  from  any  subcutaneous 
phlegmon,  however  small."  * 

In  this  connection,  one  passes  to  the  question  of  the  patho- 
genic germs  which  are  to  be  found,  and  the  role  which  they 
play.  Oilier  quoted  Rodet  f  as  stating  that  all  the  varieties 
of  juxta-epiphyseal  ostitis  might  be  produced  by  the  inocula- 
tion of  the  Staphylococcus  aureus.  And  no  form  of  coccus 
has  yet  been  discovered  in  the  acute  arthritis  of  infants 
which  is  different  from  those  found  in  acute  osteomyelitis,  so 
that  the  conclusions  of  Park  may  be  stated  as  defining  the 
character  of  the  pathogenic  germs  present  in  the  affection 
under  consideration. 

"  It  is  a  manifestation  of  the  pathogenic  properties  of 
several  micro-organisms  possessing  common  specific  pyo- 
genic activities.  It  is  a  phlegmon  of  bone  or  local  pyaemia." 
To  quote  further,  his  conclusions  are  :  (i)  that  there  is  no 
specific  microbe  for  the  production  of  acute  infectious  proc- 
esses in  bone;  (2)  most  of  the  staphylococci  can  cause  them, 
and  exceptionally  the  streptococci ;  (3)  of  all  the  forms 
the  Staphylococcus  aureus  is  the  most  pernicious,  and  of 
the  general  causes  which  favor  the  entrance  and  influence  of 
these  germs  the  tubercular,  syphilitic,  and  post-febrile  condi- 
tions are  the  most  prominent. 

In  short,  the  affection  is  to  be  considered  as  a  form  of 
pyaemia.  It  is  not  so  much  that  the  arthritis  is  the  cause  of 
pyaemia  as  that  the  joint  disease  is  pyaemia  from  the  begin- 
ning, and  that  traumatism  operates  chiefly  as  an  exciting 
cause  rather  than  as  the  real  originator  of  the  affection. 

The  relation  of  tuberculosis  to  this  affection  is  very  ob- 

*R.  Park,  Am.  Jouni.  Med.  Sci.,  July,  1889. 

t  Revue  de  Chir.,  1885  ;   Ann.  de  Gyn.  et  d'Obstet.,  1S8S,  p.  81. 


22  DISEASES    OF    THE    HIP    JOINT 

scure.  Acute  arthritis  occurs  most  often  in  feeble  children, 
perhaps  the  offspring  of  tuberculous  parents;  but  a  tuber- 
culous history  is  not  constantly  or  commonly  present.  The 
affection  is  not  one  which  has  attracted  much  attention  of 
late  years,  since  the  range  of  tuberculosis  in  joint  disease 
has  been  better  understood;  and  pathological  data  are  want- 
ing to  establish  the  proportion  of  cases  where  the  bone 
inflammation  is  tuberculous  in  character.  It  would  seem 
reasonable  to  suppose  that  some  of  the  cases  were  of  that 
nature,  and  that  in  these  the  tuberculous  process  was  of  ex- 
ceptional virulence  and  rapidity,  although  following  the  same 
course,  pathologically,  as  in  the  chronic  affections  of  older 
children.  A  careful  search  of  recent  literature  has  not  en- 
abled the  writer  to  present  any  more  definite  conclusions 
than  these  with  regard  to  the  role  of  tuberculosis  in  the 
etiology  of  this  affection. 

The  same  may  be  said  with  regard  to  inherited  syphilis. 
It  is  not  recognized  as  a  cause  of  the  affection,  nor  is  it 
known  what  influence  it  has.  On  general  principles,  it  might 
be  classed  as  a  predisposing  cause,  inasmuch  as  it  would  tend 
to  depress  the  general  condition  of  the  patient. 

Dismissing,  then,  for  the  moment  the  more  theoretical 
considerations,  one  finds  that  practically  this  affection  at- 
tacks most  commonly  children  in  the  first  year  who  are  not 
as  healthy  as  they  should  be.  Of  the  71  cases  analyzed  by 
Townsend,  20  were  less  than  four  weeks  old,  and  several 
were  in  their  first  week,  10  were  less  than  two  months  old, 
and  6  were  in  their  third  month,  making  half  of  all  the  cases 
which  occurred  in  the  first  12  weeks  of  life. 

It  can  be  seen  from  this  that  one  is  dealing  in  most  cases 
with  a  well-marked  joint  affection,  which  stands  off  clearly 
enough  from  the  usual  forms  of  the  affection  and  which 
merits  its  separate  name  and  justifies  its  individual  consider- 
ation. 

One  point,  however,  deserves  comment.  The  cases  of 
this    affection,  so    called,    which    occur    in    older    children, 


ACUTE    ARTHRITIS    OF    THE    HIP   JOINT  23 

are  open  to  the  suspicion  of  being  the  ordinary  forms  of 
tubercular  joint  disease  which  are  running  a  rapid  course. 
Tubercular  joint  disease  in  young  children  is,  as  a  rule,  acute 
and  rapid,  and  would  closely  resemble  the  affection  under 
consideration. 

To  sum  up  in  a  word  the  results  of  this  consideration  of 
the  etiology,  one  would  be  justified  in  stating  that  the  dis- 
ease was  a  pyaemic  affection  of  bone,  occurring  in  very 
young  children  ;  that  the  role  played  by  syphilis  and  tuber- 
culosis in  the  causation  of  the  affection  was  not,  as  yet, 
understood  on  account  of  insufficient  pathological  findings, 
and  that  in  older  children  the  affection  closely  resembled, 
and  was  likely  to  be  confused  with,  typical  but  rapid  cases 
of  bone  tuberculosis  ;  that,  however,  acute  arthritis  occurred 
in  young  children  as  the  result  of  syphilis,  and  probably  as 
a  distinctly  tubercular  affection,  which  will  be  considered 
under  the  proper  divisions  of  the  subject. 

Treatment. 

The  acute  sepsis  which  is  so  prominent  a  feature  in  this 
disease  is,  as  a  rule,  the  point  against  which  the  first  attack 
must  be  made  m  the  treatment  of  the  affection.  It  is  this 
which  threatens  life,  and  which  kills  the  patient  in  fatal 
cases.  Consequently,  a  strongly  supporting  treatment  must 
be  entered  upon,  as  in  the  treatment  of  pyaemia  in  general ; 
and  it  is  of  course  more  difficult  to  carry  out  such  treatment 
in  the  case  of  such  young  children  than  in  adults. 

The  use  of  alcoholic  stimulants  in  appropriate  doses  is 
indicated  from  the  first,  with  the  administration  of  quinine  ; 
and  much  dependence  must  be  placed  on  frequent  feeding 
with  appropriate  and  easily  assimilated  food,  preferably,  of 
course,  the  mother's  milk.  In  the  older  children,  the  use  of 
beef  juice  and  meat  extracts  is  of  much  benefit  from  their 
stimulant  properties.  In  the  more  asthenic  cases,  digitalis 
and  ammonia  might  prove  to  be  of  use.     Iron  should  be  ad- 


24  DISEASES    OF    THE    HIP    JOINT 

ministered  as  the  syrup  of  the  iodide,  and  is  of  much  benefit 
in  the  convalescence. 

The  local  treatment  is  often  of  greater  importance  than 
the  general,  and  in  the  milder  cases  it  is  the  chief  interest. 
Rest  to  the  joint  and  free  incision  are  the  aims  of  local  treat- 
ment. Acute  sensitiveness  of  the  diseased  joint  is  a  con- 
stant accompaniment  of  the  affection,  and  mechanical  fixation 
of  the  joint  should  be  directed  to  the  relief  of  that  symptom. 
Inasmuch  as  the  hip  is  almost  invariably  flexed  in  acute 
arthritis  (and  perhaps  adducted  as  well),  it  must  be  fixed 
and  held  in  the  position  of  deformity  without  any  attempt  to 
straighten  or  correct  it,  which  would  cause  very  much  pain. 
Fixation  of  the  joint  in  its  deformed  position  can  be  obtained 
by  Qa)  a  wire  frame,  (^b')  a  plaster  of  Paris  spica  bandage,  (<:) 
by  bed  extension  with  the  leg  on  an  inclined  plane. 

The  posterior  wire  frame  known  as  the  Cabot  frame  is  the 
most  convenient  apparatus  for  use  in  such  young  children. 
Plaster  of  Paris  becomes  soaked  with  urine,  and  softens  and 
irritates  the  skin  so  that  it  becomes  a  foul  and  irritating 
dressing  ;  and  rest  in  a  recumbent  position  is  almost  impossi- 
ble to  enforce  in  children  of  this  age.  So  that  in  all  cases 
of  acute  arthritis  of  the  hip,  before  and  after  operation  and 
v/here  no  operation  is  indicated,  a  fixative  appliance  is  an 
essential;  and  this  is  furnished  in  the  Cabot  frame.  It  is 
made  of  copper  washed  iron  wire,  one-fourth  inch  in  diameter  ; 
and  it  reaches  from  the  angle  of  the  scapula  to  the  bottom 
of  the  calf.  Above  it  should  be  as  broad  as  the  body,  and  at 
the  level  of  the  sacrum  it  should  turn  at  a  right  angle,  and 
below  that  consist  only  of  one  leg  piece,  which  should  be  as 
wide  as  "the  leg.  It  is  a  posterior  wire  splint  for  the  body 
and  for  one  leg. 

The  leg  piece  can  be  bent  to  suit  the  flexion.  So  far  as 
possible,  the  wire  should  follow  the  curves  and  outline  of  the 
trunk.  The  body  piece  should  be  padded  and  provided  with 
a  Canton  flannel  body  swathe,  and  the  leg  piece  padded  with 
Canton  flannel.     At  the  junction  of  the  leg  piece  and  the 


ACUTE    ARTHRITIS    OF    THE    HIP   JOINT 


25 


body  piece  the  wire  should  be  protected  by  rubber  tubing, 
and  the  padding  should  be  omitted  here. 

The  leg  piece  should  be  bent  as  much  as  desired,  and 
the  child  laid  on  the  frame.  The  swathe  is  pinned  about 
the  trunk  and  the  leg  bandaged  to  the  leg  piece.  The  child 
can  then  be  handled  without  jarring  the  diseased  joint. 


Fig.   I. —  cabot's  posterior  wire  frame  for  fixation  of  the  hip. 

Where  the  disease  is  seen  in  an  early  stage,  and  especially 
after  operation,  this  splint  is  of  the  greatest  use.  Traction 
is  not  necessary,  but  it  may  be  of  relief  in  quieting  the  pain. 
It  is,  however,  exceedingly  hard  to  apply  traction  to  children 
under  one  year  of  age. 

If  anchylosis  is  to  occur,  it  is  desirable  that  the  joint 
should  be  in  a  good  position,  and  not  with  a  flexed  or  ad- 


26  DISEASES    OF    THE    HIP    JOINT 

ducted  limb.  Hence  the  importance  of  early  and  accurate 
fixation  to  soothe  the  joint  and  reduce  the  muscular  irritabil- 
ity to  the  minimum. 

If  anchylosis  in  a  faulty  position  occurs,  the  treatment  is 
the  same  as  in  the  case  of  older  children  with  hip  joint 
disease. 

Incision  of  the  joint,  free  and  deep,  should  be  made  as 
soon  as  fluctuation  or  cellulitis  becomes  evident.  It  should 
follow  the  line  of  incision  adopted  for  resection  of  the  joint, 
where  practicable,  entering  the  joint  back  of  the  femur. 
The  incision  should  be  so  free  that  the  question  of  drainage 
tubes  should  not  be  discussed,  and  everything  should  be  left 
open,  while  an  antiseptic  poultice  or  a  simple  linseed  meal 
poultice  should  be  applied.  Children  under  a  year  bear  cor- 
rosive dressings  particularly  well.  An  incision  cannot  be 
made  too  early  in  these  affections  if  cellulitis  be  adopted  as 
the  indication  for  it.  Any  attempt  to  do  more  than  incise 
and  irrigate  the  joint  must  be  left  to  the  judgment  in  each 
case.  It  would  seem  more  thorough  at  least  to  scrape  away 
diseased  bone  ;  but,  if  it  is  remembered  that  the  epiphysis  is 
diseased  and  that  the  removal  of  part  or  whole  of  it  is  likely 
to  be  attended  by  much  deformity  and  retardation  of  growth, 
it  will  seem  wiser  in  most  instances  to  attempt  nothing  more 
than  the  most  superficial  removal  of  diseased  and  disinte- 
grated bone. 

The  treatment  can  be  summed  up  very  briefly  :  general, 
supporting  and  stimulating  measures  ;  local,  fixation  of  the 
diseased  joint  and  early  free  incision. 

The  bibliography  is  given  and  the  reported  cases  are  tabu- 
lated in  the  article  of  Townsend  already  referred  to. 


ACUTE    SYNOVITIS    OF    THE    HIP  2/ 


Chapter    III. 
ACUTE    SYNOVITIS    OF   THE   HIP. 

Inflammation  of  the  synovial  membrane  is  also  spoken 
of  as  arthromeningitis,  hydrops  articulorum  acutus,  sero- 
synovitis, and  acute  serous  or  purulent  synovitis,  vi^hile  puru- 
lent affections  are  spoken  of  as  empyaema  articulorum  and 
pyarthrosis. 

It  may  be  permissible  to  allude  to  the  limits  and  functions 
of  the  synovial  membrane,  in  so  far  as  the  question  affects  in- 
flammatory affections  of  this  structure.  The  synovial  mem- 
brane is  structurally  much  the  same  as  serous  membrane  ;  but 
it  differs  from  serous  membrane  in  secreting  a  peculiar 
lubricating  fluid, —  synovia, —  from  vi^hich  it  derives  its  name. 
All  diarthrodial  joints  are  lined  -with  synovial  membrane,  ex- 
cept where  the  articular  surfaces  are  in  contact,  w^here  the 
cartilage  is  bare.  The  ligaments  and  folds  of  the  capsule 
are  all  invested  with  a  synovial  covering.  The  synovial 
fringes  diversify  the  otherwise  smooth  surface  of  the  mem- 
brane, appearing  as  tufts  or  folds,  which  are  reduplications 
of  the  membrane  richly  supplied  with  blood,  or  else  protru- 
sions of  periarticular  tissues  into  the  joint. 

It  is  an  important  fact  that  the  nerves  supplying  the  joint 
surface  are  the  same  as  those  which  control  the  muscles  of 
the  limb. 

Acute  synovitis  is  to  be  classified  according  to  the  char- 
acter of  the  effusion,  as  either  serous  or  purulent.  The 
latter  is  at  times  the  outcome  of  the  former,  but  either  may 
begin  independently,  and  continue  as  it  began  throughout  its 
course.  Acute  synovitis  of  the  hip  is  classified,  according  to 
the  character  of  the  effusion,  as  serous  and  purulent. 


28  diseases  of  the  hip  joint 

Acute  Serous  Synovitis  of  the  Hip. 
Pathology. 

This  affection  first  manifests  itself  as  a  hypersemia  of  tlie 
vessels  of  the  synovial  membrane,  which  is  followed  by  stasis 
of  the  blood  current  and  dilatation  of  the  capillaries.  The 
ordinary  phenomena  of  inflammation  follow  in  regular  se- 
quence, and  migration  of  white  blood  corpuscles  occurs,  with 
a  profuse  outpouring  of  fluid  from  the  dilated  vessels.  The 
surface  cells  of  the  membrane  are  cast  off  with  undue  rapid- 
ity, and  often  give  a  flaky  appearance  to  the  effusion.  The 
effusion  may  be  slightly  discolored  with  extravasated  blood, 
especially  in  traumatic  cases. 

The  membrane  at  this  stage  looks  bright  red  and  soaked 
and  boggy.  This  latter  appearance  increases  as  time  goes 
on.  When  the  contact  with  the  fluid  has  been  longer,  this 
appearance  is  more  to  be  noticed  in  the  synovial  fringes 
than  elsewhere.  The  ligamentum  teres  appears  swollen  and 
soft. 

The  cartilage  is  not  changed  in  appearance,  but  continues 
bluish-white,  and  shows  sharply  in  contrast  to  the  bright  red 
and  sharply  defined  border  of  the  synovial  membrane. 

The  effusion  which  is  poured  out  and  distends  the  joint 
capsule  is  at  first  thinner  than  normal  synovia,  but  later  it 
may  become  very  rich  in  fibrine  and  more  scanty,  in  some 
cases  being  deposited  as  a  fibrinous  layer  on  the  joint  sur- 
faces, being  then  classed  as  a  dry  synovitis.  Distinct  flocculi 
may  be  formed  from  the  cast-off  endothelial  cells,  which  may 
be  enough  to  render  the  fluid  opalescent.  There  may  be 
much  periarticular  swelling. 

This  is  briefly  the  state  of  affairs  to  be  found  at  the  height 
of  an  acute  synovitis  of  the  hip  joint. 

Two  courses  are  now  possible :  resolution  may  take  place, 
or  the  affection  may  pass  into  the  purulent  form. 

If  resolution  is  to  occur,  the  inflammatory  process  subsides 


ACUTE    SYNOVITIS    OF    THE    HIP  29 

and  the  distended  capillaries  in  the  synovial  fringes  resume 
their  normal  calibre,  while  the  newly  formed  blood-vessels 
in  the  membrane  and  its  fringes  become  obliterated  and 
retrograde  to  connective  tissue.  The  undue  activity  in 
the  formation  of  endothelial  cells  is  checked,  and  those  al- 
ready cast  off  furnish  mucin  to  the  synovial  fluid.  With  all 
this  the  effusion  is  gradually  absorbed,  and  a  continuance  of 
these  processes  leads  to  a  cure  of  the  synovitis  ;  and  in  simple 
cases  the  joint  should  return  to  its  normal  state  without  hav- 
ing suffered  permanent  injury.  If,  however,  the  effusion  has 
been  one  very  rich  in  fibrine,  it  is  likely  that  a  certain  amount 
of  connective  tissue  formation  will  have  resulted,  which  is 
likely  to  cause  adhesions  between  the  folds  of  the  capsule,  and 
even  a  fibrous  connection  between  the  joint  surfaces  them- 
selves. This,  of  course,  results  in  impaired  motion  of  the 
joint.  Fortunately,  it  is  an  occurrence  which  rarely  takes 
place  in  simple  acute  synovitis. 

It  seems  proper  to  speak  of  the  atrophy  of  the  muscles 
which  occurs  in  connection  with  acute  inflammation  of  the 
joints,  and  which  seems  to  arise  not  so  much  from  disuse 
of  the  affected  limb  as  from  an  active  trophic  disturbance 
of  those  muscles.  The  work  of  Valtat*  did  much  to  eluci- 
date the  matter,  who  found  experimentally  that  acute  syno- 
vitis in  animals  induced  a  rapid  and  progressive  atrophy 
of  the  muscles  controlling  the  inflamed  joint,  which  was 
more  than  the  atrophy  of  disuse.  He  found  incidentally 
that  the  extensor  muscles  wasted  more  rapidly  than  the 
flexors.  The  question  of  the  origin  and  reason  of  this 
muscular  atrophy  has  been  much  discussed,  but  is  still  to  be 
explained  satisfactorily.! 

*Emile  Valtat,  L'Atrophie  Muse,  dans  les  Mai.  Artie.     Paris,  1877. 

t  Paget,  Clinical  Lectures  and  Essays,  p.  209;  Hilton,  The  Therapeutic  Influences  of  Rest, 
p.   156- 


30  diseases  of  the  hip  joint 

Acute  Purulent  Synovitis  of  the  Hip. 
PatJiology. 

If,  however,  an  acute  serous  synovitis  does  not  undergo 
resolution,  it  goes  through  a  series  of  changes  which  make 
it  a  purulent  synovitis. 

These  changes  are  practically  only  a  continuation  of  the 
processes  already  alluded  to  as  leading  up  to  acute  serous 
s3'novitis.  The  cell  migration  goes  on  unchecked  and  to  a 
greater  degree,  and  the  cell  proliferation  from  the  surface 
becomes  more  active.  The  synovial  surface  becomes  glazed, 
and  then  red  and  velvety,  and  the  fringes  seem  to  take  the 
most  active  part  in  the  process. 

From  the  admixture  of  cellular  elements  the  fluid  in 
the  joint  becomes  turbid  or  purulent,  although  merely  by 
a  continuation  of  the  same  processes  which  led  to  a  serous. 
effusion. 

The  process  may  not  go  beyond  this  stage,  and  from  this 
point  undergo  resolution.  It  is  this  degree  of  the  affection 
which  is  described  by  Volkmann*  as  "  catarrhal  inflamma- 
tion," which  he  speaks  of  as  "rather  a  perversion  of  exces- 
sive secretion  than  an  inflammatory  tissue  degeneration." 

It  should  also  be  noted  that  the  same  end  may  be  reached 
by  the  infection  of  a  serous  inflammation.  A  resolving  or 
quiescent  serous  inflammation  may  rapidly  pass  over  into 
the  purulent  stage  if  pyogenic  germs  are  introduced,  as  is 
sometimes  done  by  tapping.  Or  the  purulent  character  of 
the  inflammation  may  be  determined  in  the  beginning  by 
the  entra'nce  of  germs  through  a  Avound.  Yet,  however 
powerful  this  element  is,  it  should  be  noted  that  outside  in- 
fection is  in  no  wise  necessary  for  the  establishment  of  a 
purulent  synovitis  of  a  catarrhal  or  a  more  destructive  char- 
acter. 

If  the  svnovial  inflammation  is  to  go  on  still  further  than 

*Pitlia  and  Billroth.  Hdbch.  der  Chir.,  Bd.  ii.  2. 


ACUTE    SYNOVITIS    OF    THE    HIP  3 1 

the  stage  already  described,  the  same  processes  merely  con- 
tinue and  increase.  The  cartilages  become  yellow  and 
opaque,  and  are  the  seat  of  cell  proliferation  and  fibrillary 
degeneration,  to  be  considered  in  detail  in  the  next  chapter. 
Spots  of  erosion  form,  and  bone  may  be  more  or  less  bared  ; 
but  these  extreme  changes  belong  rather  to  the  domain  of 
chronic  synovitis,  as  do  those  more  advanced  conditions  of 
the  synovial  membrane  where  the  membrane  becomes  one 
general  granulating  surface,  secreting  pus  in  great  quantities. 

The  capsule  may  burst  from  distention  and  softening,  and 
the  pus  pour  into  the  periarticular  tissues,  where  it  reaches 
the  surface  as  an  abscess  ;  but  these  and  the  other  more  de- 
structive changes  will  be  considered  in  the  following  section. 

At  any  stage  of  the  process  resolution  may  occur,  and  the 
amount  of  limitation  of  the  joint  motion  will  be  determined 
by  the  amount  of  granulation  tissue  which  has  occurred  in 
the  synovial  membrane.  It  must  of  course  retrograde  to 
fibrous  tissue,  and,  if  this  is  present  to  any  large  extent,  a 
certain  cicatricial  contraction  of  the  capsule  will  result,  which 
means  necessarily  impaired  motion.  In  the  simple  catarrhal 
variety,  however,  perfect  restoration  of  motion  is  not  unlikely 
to  occur.  If  the  cartilages  should  be  destroyed  and  eroded, 
however,  it  is  a  more  serious  matter. 

Hydrops  articulormn  ttiberailosjis,  as  described  by  Konig,* 
should  be  described  here,  although,  perhaps,  partaking  as 
much  of  the  character  of  a  chronic  as  of  acute  inflamma- 
tion. 

It  is  found  as  a  diffuse  inflammation  of  the  synovial  mem- 
brane, which  is  found  to  be  studded  with  tubercles,  and  the 
membrane  in  which  they  lie  imbedded  is  succulent  and 
boggy.  The  effusion  may  be  serous,  sero-purulent,  or  puru- 
lent ;  and  it  may  be  fibrinous  in  character,  perhaps  even 
leading  to  the  formation  of  foreign  bodies. 

This  form  of  synovial  tuberculosis,  generally,  although  not 

*Die  Tuberculosis  der  Knochen  u.  Gelenke.    Berlin,  1SS4. 


32  DISEASES    OF    THE    HIP    JOINT 

necessarily,    coexists  with   tuberculosis    of    the  neighboring 
bone. 

Etiology. 

Acute  synovitis  is  due  to  many  and  differing  causes. 

(i)  Traumatism  is  one  of  the  most  frequent  and  definite 
causes.  It  is  ordinarily  a  serous  synovitis  which  is  caused 
in  this  way,  unless  the  joint  be  opened  by  a  penetrating 
wound,  in  which  case  the  synovitis  will  probably  be  purulent. 
In  the  hip  joint,  of  course,  penetrating  wounds  are  very  rare, 
and  traumatic  synovitis  here  is  generally  a  simple  serous 
one.  It  is  likely  to  be  caused  by  falls  and  wrenches  of  the 
leg,  by  blows  or  falls  upon  the  trochanter  and  the  like ;  but 
it  is  much  less  likely  to  occur  than  synovitis  of  the  other  leg 
joints, —  the  ankle  and  the  knee.  The  hip  is  such  a  deep- 
seated  and  firmly  protected  joint,  and  so  thoroughly  con- 
trolled by  the  strongest  muscles  and  ligaments  in  the  body, 
that  any  moderate  grade  of  injury  is  much  more  likely,  for 
obvious  mechanical  reasons,  to  take  effect  upon  either  of  the 
more  exposed  and  less  protected  joints  of  the  leg,  so  that 
sprained  knees  and  ankles  are  vastly  more  common  than 
sprained  hips.  It  should  be  remembered  that  synovitis  of 
the  hip  follows  all  forms  of  dislocation  of  that  joint. 

(2)  Over-exertion  is  sometimes  followed  by  synovitis,  but, 
here  again,  much  more  commonly  by  synovitis  of  the  knee 
than  of  the  hip. 

(3)  Exposure  to  cold  or  wet,  although  a  frequent  cause  of 
synovitis  of  the  knee,  can  hardly  be  classed  as  more  than  a 
possible  cause  of  hip  synovitis. 

(4)  Acute  articular  rheumatism  is  at  times  a  cause,  and 
one  of  the  most  frequent  causes  of  synovitis  of  the  hip.  In  a 
series  of  cases  of  joint  affections  occurring  in  acute  rheuma- 
tism (compiled  from  series  of  cases  by  Haygarth,*  Hersch,t 
Monneret,t   and    St.   Bartholomew's  Hospital),  the  relative 

*Clin.  Hist,  of  Acute  Rheumatism.     1S05. 

t  Mittheilungen  aus  der  Med.  Klin,  zu  Wiirzburg,  18S6,  ii.  p.  277. 

JLa  Goutte  et  la  Rhumatisme.     These  de  Concours.     Paris,  1851. 


ACUTE    SYNOVITIS    OF    THE    HIP  33 

frequency  of  hip  synovitis  is  shown  by  comparison  with  the 
other  articulations. 


The  knee  was  affected        357  f 

The  ankle  was  affected       28. 

The  wrist  was  affected        249  t 

The  shoulder  was  affected 229  t 

The  elbow  was  affected 148  t 

The  hip  was  affected 103  t 

The  fingers  were  affected        81  t 

The  feet  were  affected        45  t 

The  hands  were  affected 44  t 

The  toes  were  affected       29  t 

The  spine  was  affected 16  t 

Miscellaneous  joints 8  t 

Total  joints  affected 1,593  t 


mes 
mes 
mes 
mes 
mes 
mes 
mes 
mes 
mes 
mes 
mes 
mes 

mes 


Senator*  has  found  the  fluid  from  joints  affected  by  acute 
articular  rheumatism  to  be  alkaline  in  reaction  and  rich  in 
albumen  and  fibrine ;  but  Bouchard  f  reported  cases  where  it 
was  acid,  so  that  nothing  definite  can  be  stated  in  this  re- 
gard. 

In  this  form  of  synovitis  the  development  is  very  rapid, 
and  there  is  no  tendency  to  pus  formation.  It  is  essentially 
a  multiple  form  of  synovitis,  and  spreads  with  much  rapidity 
from  joint  to  joint.  It  is  suggested  by  Monneret  that  the 
arthritis  is  a  phenomenon  much  like  the  cutaneous  ery- 
themata  of  the  disease  ;  but  beyond  this,  little  is  known 
about  it  beside  the  fact  that  the  great  majority  of  all  pa- 
tients affected  by  rheumatism  suffer  from  joint  symptoms. 

(5)  Gout  is  the  cause  of  a  certain  very  small  number  of 
attacks  of  acute  synovitis  of  the  hip.  The  joint  is  attacked 
by  an  acute  synovitis  of  the  ordinary  type,  which  tends  to 
pass  on  into  a  chronic  form,  characterized  by  the  deposit  of 
urate  of  soda  in  the  synovial  membrane,  the  capsule,  and 
the  periarticular  structures. 

*Ziemssen,  Hdbch.,  1879;  2d  ed.,  vol.  xiii. 

t  Bouchard,  Mai.  par  Raltntissement  de  la  Nutrition,  1882,  p.  318. 


34  DISEASES    OF    THE    HIP    JOINT 

The  attacks  are,  in  the  great  majority  of  all  cases,  located 
in  the  great  toe,  and  the  hip  is  but  rarely  affected.  In 
198  cases  reported  by  Scudamore,  140  had  the  disease  in  the 
great  toe  joint. 

(6)  Syphilis  is  an  uncommon,  but  still  a  recognized  cause 
of  acute  synovitis.  As  a  cause  of  chronic  inflammation,  it  is 
more  frequently  met.  Acute  synovitis  occurs  at  times  {a) 
in  connection  with  the  secondary  symptoms,  such  as  the 
iritis,  the  eruption,  and  the  pharyngitis.  Na  post-mortem 
reports  of  this  condition  have  been  reported,  and  the  hip  is 
not  commonly  affected,  {b)  A  simple  serous  joint  inflam- 
mation, with  rather  a  chronic  tendency,  occurs  in  connection 
with  some  cases  of  hereditary  syphilis. 

The  joints  are  affected  in  syphilitic  disease  in  the  order 
named  below,  from  which  it  will  be  seen  that  the  hip  is  not 
often  diseased  from  this  cause.  The  knee,  the  elbow,  the 
fingers,  the  toes,  the  metacarpo-  and  metatarso-phalangeal 
joints,  the  wrist,  the  hip,  and  the  ankle  are  affected  in  the 
order  named. 

(7)  Infections  diseases  as  a  cause  of  acute  synovitis  are 
well  recognized ;  and,  although  no  very  satisfactory  explana- 
tion of  their  action  can  be  given,  they  must  be  regarded  as  a 
comparatively  frequent  cause  of  acute  serous  or  purulent 
synovitis  of  the  hip, —  unfortunately,  most  often  the  latter. 
In  general,  it  may  be  said  that  the  affection  most  closely  re- 
sembles a  pyaemic  process  ;  such  infection  of  the  joints  being, 
in  fact,  a  classical  symptom  of  pyaemia. 

The  diseases  in  which  such  joint  inflammations  occur  are 
as  follows  ;  diphtheria,  dysentery,  erysipelas,  malaria,  measles, 
meningitis,  pneumonia,  pertussis,  parotitis,  pyaemia,  puer- 
peral fever,  scarlet  fever,  septicaemia,  small-pox,  typhus  and 
typhoid  fevers,  and  varicella.  Gonorrhoea  and  the  use  of 
catheters  are  probably  to  be  grouped  with  these  diseases  as 
possible  causes  of  synovitis. 

The  joint  complication  in  gonorrhoea  most  often  occurs 
during    or  after   the   convalescence  from   the  acute  attack, 


ACUTE    SYNOVITIS    OF    THE    HIP  35 

generally  after  the  second  week.  These  attacks  may  be 
serous  or  purulent.  If  the  former,  they  tend  easily  to  sup- 
puration. 

The  joint  infection  in  these  diseases  is  attributed  to  the 
presence  of  micro-organisms  in  the  circulation,  and  in  the 
fluid  from  such  joints  micro-organisms  are  to  be  found.  In 
the  purulent  and  more  severe  cases  one  finds  staphylo- 
coccus and  streptococcus  pyogenes  in  enormous  numbers, 
and  in  the  serous  cases,  milder  forms,  so  that  it  seems  as  if 
whether  the  synovitis  were  serous  or  purulent  were  deter- 
mined by  the  character  of  the  micro-organisms  reaching  the 
joint  rather  than  by  any  other  factor.* 

In  most  cases,  the  organisms  reach  the  joint  without  doubt 
through  the  circulation  ;  but  they  may  at  times,  as  in  puer- 
peral fever  or  erysipelas,  reach  the  hip  by  the  lymphatics 
or  by  direct  extension.! 

The  character  of  gonorrhoeal  synovitis  has  been  much  dis- 
puted, but  its  proper  place  seems  to  the  writer  to  be  here. 
The  theory  of  William  Ord  that  it  is  the  result  of  a  reflex 
nervous  disturbance  does  not  seem  tenable.  Gonococci 
have  been  found  in  the  joint  fluid,  J  and  the  clinical  character 
of  the  affection  tends  to  make  it  seem  like  the  synovitis  of 
the  other  infectious  diseases. 

Gonorrhoeal  synovitis  affects  the  knee  most  often  and  the 
hip  infrequently.  The  joints  are  affected  as  follows  in  the 
order  named  :  Of  308  cases, §  86  attacked  the  knee,  52  the 
foot,  29  the  shoulder,  26  the  hand,  17  the  fingers  and  toes,  16 
the  metatarso-phalangeal  joints,  15  the  hip. 

Many  of  these  infectious  diseases  also  are  the  cause  of 
tuberculous  ostitis  of  the  hip  in  children  and  of  the  acute 
arthritis  of  the  hip  in  infants.  In  some  instances,  this  is 
undoubtedly  at  first  a  synovitis  ;  but  in  most  cases,  it  will  be 

♦Arch.  f.  Klin.  Chir.,  xxxi.,  Heft  2  ;  Ziemssen's  Hdbch.,  2  Auflage,  ii.  p.  546;  Cent,  f  Chir.^ 
Sitzberichte  d.  Cong.  f.  Chir. ,  1884. 

t  Bradford  and  Lovett,  Treat,  on  Orth.  Surgery.     iSgo. 

t  Petrone,  Revista  Clinica,  1883,  No.  2  ;  Cent.  f.  Chir.,  1884,  No.  4. 

§Nolen,  Archiv  f.  Klin.   Med.,   18S2,  xxxii.  p.  120. 


36  DISEASES    OF    THE    HIP   JOINT 

seen,  there  is  reason  to  believe  that  the  original  lesion  is  an 
osteomyelitis. 

Acute  purulent  synovitis,  when  secondary  to  a  lesion  of 
the  bone,  will  be  considered  under  the  heading  of  diseases 
primarily  osseous. 

Treatment. 

Simple  acute  synovitis  of  the  hip  is  to  be  treated  by  rest 
and  counter-irritation.  Rest  to  the  joint  is  most  readily  to 
be  obtained  in  bed,  with  the  hip  controlled  by  a  long  outside 
splint  or  a  plaster  of  Paris  spica  bandage.  If  there  is  much 
pain  and  muscular  irritability,  traction  will  add  much  com- 
fort, exerted  by  means  of  a  weight  and  pulley  drawing  down 
upon  the  leg  by  means  of  adhesive  plaster  straps.  Rest  to 
the  joint  should  be  insisted  upon  until  motion  is  free  and 
painless. 

The  hip  joint  is  so  deeply  seated  that  it  is  not  accessible 
to  compression,  so  useful  in  the  synovitis  of  other  joints,  and 
counter-irritation  must  take  its  place.  This  is  most  readily 
obtained  by  a  fly  blister  back  of  the  trochanter  or  by  hot 
stimulating  applications  to  the  flank. 

If  an  abscess  forms,  it  must  be  opened  freely,  most  con- 
veniently by  the  conventional  cut  for  hip  excision.  In  the 
more  rapid  forms  of  acute  infectious  purulent  synovitis,  a 
free  incision  is  to  be  made  so  soon  as  fluctuation  is  detected. 
Ordinarily,  it  will  be  better  to  wait  until  the  collection  of  pus 
reaches  the  surface. 

The  T'eatjnejit  of  Acute  Synovitis  of  the  Hip  in  Children. 

To  the  writer's  mind  this  section  of  the  subject  is  worthy 
of  the  most  careful  consideration.  Children  are  not  prone  to 
suffer  from  simple  acute  synovitis  :  it  is  not  the  way  in  which 
their  joints  commonly  react  to  an  irritant  or  an  injury.  The 
tendency  is  to  ostitis  and  to  chronic  degenerative  synovitis. 
Nowhere  is  this  more  true  than  at  the  hip.    Practical  experi- 


ACUTE    SYNOVITIS    OF    THE    HIP  37 

ence  shows  that  simple  acute  synovitis  of  the  hip  which 
clears  up  and  leaves  a  healthy  joint  in  children  is  very  rare. 
The  fact  is  not  altogether  to  be  explained,  but  it  must  rest  on 
the  basis  of  experience.  On  the  other  hand,  let  it  be  remem- 
bered that  hip  disease  very  often  is  noted  as  beginning 
acutely.  In  a  large  numerical  proportion  of  all  cases  it  is 
attributed  directly  to  some  injury,  as  is  well  known  ;  and  in 
most  cases  the  symptoms  after  the  injury  are  those  of  acute 
synovitis.  Now,  the  practical  outcome  of  the  matter  is  that 
these  cases  of  apparent  acute  synovitis  are  really  beginning 
hip  disease,  which  may  have  been  excited  by  the  injury  or 
may  not.  The  fact  remains  the  same,  that  the  surgeon  who 
makes  the  diagnosis  of  simple  acute  synovitis  in  these  cases 
lays  himself  open  to  a  very  great  chance  of  error,  as  must  be 
manifest.  How  common  such  cases  are  must  be  a  matter  of 
experience  to  every  surgeon  who  sees  much  of  children. 

Remissions  in  hip  disease,  in  which  the  symptoms  practi- 
cally disappear  and  the  signs  improve  radically,  are  so  com- 
mon that  they  require  no  comment.  This  simply  adds  to  the 
obscurity  in  making  the  resemblance  of  early  hip  disease 
and  acute  synovitis  the  more  close,  in  their  clinical  history 
as  well  as  their  symptoms.  Therefore,  not  only  should  the 
diagnosis  of  simple  hip  synovitis  be  made  with  much  reserve 
in  young  children,  but  also  the  treatment  should  be  con- 
ducted with  great  care,  and  not  be  discontinued  so  long  as 
any  suspicion  of  hip  disease  remains. 

If  the  writer  may  allude  once  more  to  his  own  experience, 
it  has  led  him  never  to  make  a  diagnosis  of  acute  synovitis 
of  the  hip  in  a  child  until  some  time  after  its  complete  and 
speedy  recovery  from  all  symptoms.  This  is,  perhaps,  a 
matter  which  belongs  more  to  the  diagnosis  than  to  the 
treatment ;  but  its  extreme  practical  importance  makes  it 
justifiable  to  allude  to  it  here. 

The  treatment  should,  of  course,  be  the  same  as  that  de- 


38  DISEASES    OF    THE    HIP    JOINT 

scribed  above,  except  that,  if  at  the  end  of  a  week  the  condi- 
tion is  not  decidedly  improved,  traction  should  always  be 
added,  and  the  child  should  not  be  allozved  to  walk  07i  the 
affected  leg  until  some  time  after  all  symptoms  have  disap- 
peared. If  the  symptoms  persist,  the  child  should  be 
treated  for  hip  disease  without  delay. 


CHRONIC    SEROUS    SYNOVITIS    OF    THE    HIP    JOINT  39 


Chapter    IV. 

CHRONIC   SEROUS   SYNOVITIS  OF   THE  HIP 
JOINT. 

Forms  of  chronic  serous  synovitis  of  the  hip  which  are  not 
associated  with  the  occurrence  of  tubercles  or  included  in 
the  manifestations  of  that  affection  known  as  arthritis  defor- 
mans or  rheumatoid  arthritis,  are  so  uncommon  that  they 
need  not  receive  extended  consideration.  Tuberculous  syno- 
vitis and  arthritis  deformans  will  be  considered  under  their 
own  divisions. 

Pathology. 

Chronic  synovitis  of  the  hip  may,  however,  succeed  an 
acute  synovitis.  It  may  start  de  novo  as  a  dropsy  of  the 
joint,  so  called,  or  it  may  appear  as  a  low-grade  inflamma- 
tion with  a  scanty  effusion,  and  associated  with  a  strong  ten- 
dency toward  connective-tissue  degeneration  of  the  cartilage 
and  obliteration  of  the  joint  by  fibrous  anchylosis. 

Succeeding  an  attack  of  acute  synovitis,  one  finds  that  an 
increased  vascularity  of  the  synovial  membrane  is  followed 
by  a  thickening  and  bogginess  of  it,  which  is  increased  by 
its  contact  with  the  joint  effusion.  The  capsule  becomes 
thickened  and  softened,  and  the  ligamentura  teres  swollen 
and  soft.  The  subsynovial  tissues  become  swollen  and  the 
ligaments  thickened  and  less  firm.  In  a  joint  less  protected 
structurally  it  would  lead  to  abnormal  mobility.  The  slight 
synovial  fringes  which  exist  in  the  hip  become  hypertro- 
phied,  and  appear  papillomatous,  but  not  to  such  an  extent 
as  occurs  in  the  knee. 


40  DISEASES    OF    THE    HIP    JOINT 

On  the  other  hand,  considerable  effusion  may  rarely  be 
found  in  the  hip  joint,  as  is  so  much  more  frequently  the  case 
in  the  knee,  where  the  pathological  changes  are  but  slight. 
It  is  to  such  cases  that  the  names  dropsy  of  the  joint,  hy- 
drarthron,  etc.,  are  given.  Although  it  was  originally  con- 
sidered to  be  an  affection  which  was  non-inflammatory,  the 
weight  of  modern  opinion  inclines  to  class  it  as  a  low-grade 
inflammatory  affection,  accompanied  by  a  copious  effusion,* 
with  slight  structural  changes  in  the  synovial  membrane. 

Finally,  there  may  be  found  in  the  hip  joint  the  third 
affection  spoken  of  above,  which  was  formerly  classed  as  a 
"dry  synovitis,"  but  which  is  now  spoken  of  more  commonly 
as  arthrite  plastiqiie  ankylosante,  or  arthritis  chronica  an- 
kylopoctica. 

The  former  idea  was  that  a  scanty  effusion  rich  in  fibrine 
was  poured  out,  which  led  to  a  gluing  together  of  the  joint 
surfaces.  This  may  occur  in  acute  cases  ;  but  in  the  chronic 
form  of  the  affection  modern  pathology  has  gone  on  to  the 
observation  of  more  extended  and  significant  changes,  and 
allows  but  little  importance  to  the  plastic  power  of  the  effu- 
sion in  itself. 

These  changes  differ  from  those  found  in  arthritis  defor- 
mans only  in  a  slight  degree,  but  chiefly  in  the  cartilaginous 
part  of  the  joint.  In  arthritis  ankylopoetica,  or  ankylosing 
arthritis,  proliferation  of  the  cartilage  exists  only  in  a  slight 
degree;  and  the  changes  on  the  cartilaginous  surface  partake 
less  of  the  nature  of  a  disintegration,  being  rather  a  change 
to  connective  tissue. 

In  the  earlier  stages  of  the  affection  the  synovial  mem- 
brane appears  thickened  and  more  injected  than  it  should  be 
normally,  while  the  slight  fringes  tend  to  hypertrophy.  In 
addition  to  these  changes,  however,  and  more  significant, 
one  finds  that  the  cartilaginous  surface  is  roughened,  with 

*  Diet,  de  Med.  et  Chir.  Prat.,  viii.  89;  Bonnet,  Malad.  des  Artie,  Paris,  1 84 5 ;  Billroth, 
Surg.  Path.,  Am.  Ed.,  1883,  p.  578;  Billroth,  Arch.  f.  Klin.  Chir.,  ii.  408;  Cornil  and  Ranvier, 
Histology;   H.  Marsh,  Dis.  of  Jts. 


CHRONIC    SEROUS    SYNOVITIS    OF    THE    HIP    JOINT  4I 

a  tendency  toward  fibrillary  degeneration,  and  that  certain 
parts  have  hypertrophied  or  have  been  made  thicker  by  the 
deposition  of  layers  of  fibrine  on  the  surface.  In  the  deeper 
layers  of  the  cartilage,  next  to  the  articular  end  of  the  bone, 
there  is  a  tendency  toward  increased  vascularity  and  change 
to  osteoid  tissue. 

A  very  important  factor  in  the  joint  obliteration  is  now  to 
be  noticed  ;  namely,  a  vascularization  of  the  cartilage.  Blood- 
vessels are  to  be  seen  here  and  there  in  the  stage  subse- 
quent to  the  one  just  described,  which  play  an  important  role. 
In  part  they  are  derived  from  the  synovial  membrane  and 
in  part  from  the  subsynovial  tissue,  as  well  as  from  the  syno- 
vial fringes.  In  proportion  to  the  number  and  size  of  these 
is  to  be  estimated  the  rapidity  of  the  joint  change,  which  is 
essentially  a  fibrinous  gluing  together  of  the  surfaces  along 
with  a  fibrillary  degeneration  of  the  cartilage.  The  first  ad- 
hesions form  in  the  neighborhood  of  these  vessels,  and  these 
bands  grow  larger  and  firmer  and  shut  off  more  and  more  of 
the  joint. 

This  condition  of  fibrous  anchylosis  is,  in  most  cases,  suc- 
ceeded by  a  deposition  of  bone  in  the  fibrous  tissue,  resulting 
in  a  bony  anchylosis  and  complete  obliteration  of  the  affected 
joint. 

It  may  seem  a  distinction  of  unnecessary  accuracy  to  de- 
scribe this  affection  separately  from  arthritis  deformans,  but 
in  doing  so  the  writer  only  follows  the  example  of  Ziegler 
and  the  best  modern  pathologists. 

Etiology. 

Aside  from  the  forms  of  hip  synovitis  associated  with 
tuberculosis  and  arthritis  deformans  there  is  little  to  be  said 
in  considering  the  etiology  of  this  affection. 

Certain  cases  are  the  outcome  of  attacks  of  acute  syno- 
vitis, the  result  either  of  .traumatism  or  rheumatism,  or  in 
those  instances  where  no  cause  can  reasonably  be  assigned 


42  DISEASES    OF    THE    HIP    JOINT 

for  the  attack.  Cases  which  begin  de  novo  as  chronic  serous 
synovitis  are  rare.  For  the  most  part,  this  form  occurs  in 
young  adults,  and  is  apt  to  be  associated  with  rheumatism, 
in  which  case  it  is  most  often  polyarticular. 

Gonorrhoea  should  also  be  mentioned  as  a  possible  cause  of 
chronic  serous  synovitis,  although  occurring  most  often  in 
connection  with  an  acute  or  chronic  purulent  form, 

Gont,  by  a  succession  of  acute  attacks,  induces  a  condition 
of  practically  chronic  synovitis,  in  which  the  synovial  mem- 
brane is  the  seat  of  urate  of  soda  deposit,  and  stiffness  of  the 
joint  ensues. 

Syphilis  affects  the  hip  joint  sometimes  during  the  sec- 
ondary stage  of  the  disease,  occurring  as  a  subacute  serous 
synovitis,  accompanied  by  much  swelling.  It  appears  as  a 
cause  of  joint  inflammation  more  often  at  a  later  period, 
when  the  disease  is  well  advanced  into  its  tertiary  stage,  and 
appears  generally  in  a  chronic  monarticular  type.  It  is  char- 
acterized by  marked  effusion,  accompanied  by  much  thicken- 
ing of  the  capsule  and  papillary  hypertrophy  of  the  synovial 
fringes. 

Gummata  often  appear  in  the  synovial  membrane,  the  cap- 
sule or  the  ligaments;  and  there  is  but  slight  tendency 
toward  the  formation  of  pus.  Where  resolution  takes  place, 
it  is  generally  accompanied  by  contraction  of  the  thickened 
capsule. 

Chronic  ankylosing  arthritis  is  also  spoken  of  as  artki'itis 
pajipej'um,  which  explains  very  succinctly  the  chief  class 
affected  by  it.  Associated  in  most  instances  with  chronic 
rheumatic  changes  in  the  other  joints,  it  is  to  be  accounted 
the  outcome  of  unfavorable  conditions,  such  as  damp  dwell- 
ings, poor  and  insufficient  food,  exposure,  and  the  like.  It 
affects  old  persons,  and  mostly  those  in  poor  general  con- 
dition otherwise. 

Practically,  it  is  not  always  to  be  differentiated  from  the 
similar  condition  of  arthritis  deformans. 


chronic  serous  synovitis  of  the  hip  joint         43 

Treatment. 

The  treatment  of  chronic  serous  synovitis  of  the  hip,  apart 
from  the  two  varieties  which  are  not  under  consideration 
here,  is  a  question  which  comes  up  but  rarely  in  practice. 

A  long  continuance  of  symptoms  of  chronic  hip  synovitis 
would  lead  to  the  suspicion  of  the  existence  of  tubercular 
disease,  and  to  the  adoption  of  the  treatment  for  that  affec- 
tion. Before  that  the  measures  most  likely  to  be  of  use 
would  be  the  administration  of  anti-rheumatic  remedies  and 
a  building  up  of  the  general  health.  Locally,  compression  is 
not  available ;  and  one  must  depend  upon  counter-irritation 
by  blisters  or  the  Pacquelin  cautery,  with  protection  and 
rest  to  the  affected  limb,  most  easily  to  be  obtained  by  the 
use  of  a  high  shoe  on  the  well  leg,  with  crutches,  so  that  the 
affected  leg  would  swing  in  walking.  Massage  should  be 
tried  to  assist  in  the  absorption  of  the  fluid.  The  treatment 
of  chronic  ankylosing  arthritis  is  identical  with  that  of  arthri- 
tis deformans,  and  will  be  discussed  under  that  heading. 

Chronic  Purulent  Synovitis  of  the  Hip  Joint. 

The  changes  here  are  so  inextricably  associated  with  the 
osseous  changes  that  a  consideration  of  the  synovial  changes 
by  themselves  would  involve  much  repetition  and  lead  to 
obscurity.  It  seems  best,  therefore,  to  consider  the  changes 
in  chronic  purulent  synovitis  in  the  next  chapter. 


44  DISEASES    OF    THE    HIP    JOINT 


Chapter    V. 

TUBERCULOUS    OSTITIS    OF   THE   HIP 
{Hip  Disease). 

INCLUDING    CHRONIC    PURULENT   SYNOVITIS. 

There  are  two  well-recognized  forms  of  degenerative  ostitis, 
the  one  characterized  by  the  formation  of  tubercles,  the  other 
by  the  presence  of  guramata  in  the  diseased  tissue. 

The  bone  changes  occurring  in  arthritis  deformans  will  be 
discussed  separately. 

The  divisions  of  the  subject  are  :  — 

{a)  Tuberculous  ostitis. 

{b)  Gummatous  ostitis. 

{a)  Tnberciiloiis  Ostitis  (including  chronic  purulent  syno- 
vitis). 

The  great  bulk  of  all  cases  of  disease  of  the  hip  joint  is 
made  up  by  a  chronic  degenerative  process,  characterized 
by  the  formation  of  tubercles,  a  process  which  sometimes 
begins  in  the  bone  and  sometimes  in  the  synovial  membrane. 
The  result  is  the  same,  and  practically  the  diagnosis  cannot 
be  made  between  the  two  conditions.  It  seems  best,  there- 
fore, to  speak  of  the  whole  affection  by  its  accepted  name 
of  hip  disease,  and  to  discuss  in  one  place  the  synovial, 
cartilaginous,  and  osseous  changes,  which  go  hand  in  hand 
in  chronic  tuberculous  ostitis  of  the  hip,  commonly  called 
"  hip  disease." 


TUBERCULOUS    OSTITIS    OF    THE    HIP  45 


Hip   Disease  :   Pathology. 

The  affection  is  known  more  exactly  as  hip  joint  disease. 
Also  it  is  called  Coxalgia,  Morbus  Coxae,  Morbus  Coxarius, 
Caries  of  the  Hip,  Coxotuberculose,  Coxalgie,  Huftgelenk- 
krankheit,  etc. 

Chronic  articular  ostitis  of  the  hip  is  a  more  exact  patho- 
logical name  sometimes  used. 

It  belongs  to  the  class  of  joint  disease  spoken  of  in  other 
joints  (as  well  as  in  the  hip)  as  fungous  joint  disease,  stru- 
mous arthritis,  scrofulous  joint  disease,  etc. 

In  German  similar  names  are  fungdse  Gelenkentziindung, 
die  granulirend  tuberculose  Gelenkentziindung,  and  Glied- 
schwamm  ;  and,  in  French,  Tuberculose  articulaire.  Osteite 
aigue,  etc. 

The  affection  begins  primarily  either  in  the  synovial  mem- 
brane or  in  the  spongy  tissue  of  the  bone,  and,  secondarily, 
affects  the  other  in  most  cases.  The  cartilage  plays  only  a 
passive  role. 

Synovial  Changes. 

An  affection  of  the  synovial  membrane  has  been  described 
by  Konig  which  he  has  called  Hydi^ops  Articiilorum  Tuber- 
culosus.  This  form  of  disease  is  found  most  often  in  connec- 
tion with  the  tuberculosis  of  neighboring  bone,  although  not 
necessarily  so. 

The  synovial  membrane  is  thickened  and  succulent  most 
often,  and  studded  with  tubercles  which  extend  even  into  the 
subsynovial  tissue.  On  the  other  hand,  the  tubercles  may 
be  present  in  a  synovial  membrane,  almost  unchanged  by  in- 
flammation. The  effusion  is  generally  copious  and  serous 
or  sero-purulent,  and  the  synovial  tissue  tends  to  granula- 
tion, and  the  affection  shades  into  the  common  form  of 
fungous  synovitis  about  to  be  described. 


46  DISEASES    OF    THE    HIP    JOINT 

It  exists,  however,  often  enough  alone  to  be  described  as 
an  individual  affection*  pathologically.  It  should  be  men- 
tioned, in  connection  with  it,  that  the  effusion  in  some  cases 
is  very  fibrinous,  and  shows  a  strong  tendency  toward  co- 
agulation and  the  formation  of  loose  bodies  in  the  joints. f 
It  is  not,  however,  the  usual  form  of  tuberculosis  of  the 
synovial  membrane.  Konig  finds  an  explanation  for  this 
particular  form  of  joint  disease  in  assuming  that  the  irrita- 
tion caused  by  the  growth  of  the  tubercles  in  these  cases  is 
not  enough  to  cause  the  ordinary  manifestation  as  fungous 
granulations. 

The  common  form  of  tuberculosis  of  the  synovial  mem- 
brane results  in  changes  in  the  membrane  which  lead  to  a 
purulent  effusion. 

The  affection  may  be  the  outcome  of  an  acute  synovitis 
which  has  passed  into  the  chronic  state  or  it  may  begin 
merely  as  a  chronic  affection  at  the  first. 

If  the  affection  was  originally  an  acute  purulent  synovitis, 
a  persistence  of  the  condition  described  in  speaking  of  that 
would  lead  to  a  chronic  synovial  disease.  If  it  was  originally 
an  acute  serous  synovitis,  certain  transitional  stages  are  to 
be  noticed.  The  injection  of  the  synovial  membrane  con- 
tinues, and  leads  to  its  hypertrophy  and  thickening.  The 
increased  blood  supply  and  contact  with  the  effusion  make 
the  membrane  succulent  and  boggy.  At  the  edges  of  the 
cartilages  it  encroaches  upon  them  and  corrodes  them.  The 
increased  activity  leads  to  the  formation  of  white  blood 
corpuscles,  and  their  accumulation  as  granulation  tissue, 
which  causes  a  change  in  the  effusion  from  a  serous  to  a 
sero-purulent  or  purulent  one. 

The  first  stage  of  inflammation  in  a  synovial  membrane 
infected  by  tubercle  bacilli  consists,  then,  in  increased  vas- 
cularity, thickening  and  succulency  of  the  synovial  mem- 
brane,  accompanied  by  a  serous  or  sero-purulent    effusion. 

*  Konig,  Die  Tuberc.  der  Knochen  und  Gelenke,  Berlin,  1SS4,  p   22. 
tRiedel,  Deutsch.  Zcitsch.  f.  Chir.,  Bd.  xx. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  47 

This  condition  gradually  merges  into  the  formation  of  a  low- 
grade  granulation  tissue,  which  occupies  the  surface  of  the 
membrane  and  which  is  best  described  by  the  term  gelati- 
nous. In  the  hip  joint  this  gelatinous  degeneration  is  not  so 
common  as  in  the  knee,  for  instance,  and  more  commonly  one 
finds  a  swollen  and  reddened  membrane  with  comparatively 
firm  granulation  tissue. 

During  this  process  the  synovial  membrane  grows  over  on 
to  the  cartilage,  and,  where  it  covers  it,  it  becomes  adher- 
ent, and,  if  peeled  off,  it  shows  that  the  underlying  cartilage 
has  been  eroded.  Such  synovial  fringes  as  there  are  in  the 
hip  joint  hypertrophy  and  take  an  active  part  in  the  process. 

Imbedded  in  the  granulation  masses  are  small  white  specks, 
just  visible  to  the  naked  eye,  which  are  to  be  identified  as 
tubercles.  Later  they  appear  in  larger  masses,  and  perhaps 
tend  to  cheesy  degeneration  in  the  larger  nodules. 

The  secretion  from  these  granulating  synovial  surfaces,  as 
a  rule,  is  small  in  the  hip.  When  one  considers  how  little 
effusion  can  be  contained  in  this  joint,  and  considers  how 
comparatively  uncommon  hip  abscess  is  in  well-treated  cases 
of  hip  disease,  it  must  be  evident  that  excessive  secretion  of 
pus  is  not  the  rule.  In  some  instances,  little  or  no  effusion 
is  present  in  the  joint  (Lannelongue),  even  when  the  disease 
is  well  advanced. 

Microscopically,  the  granulations  are  seen  to  consist  of 
typical  granulation  tissue,  interspersed  with  the  white  specks 
already  alluded  to,  which  are  of  the  greatest  significance. 
For  a  long  time  their  importance  was  overlooked,  and  they 
were  first  recognized  as  tubercles  by  Koster.*  Their  struct- 
ure in  the  early  stages  is  typical  of  that  pathological  condi- 
tion known  as  tubercle.  Later,  as  they  become  cheesy  and 
disintegrated,  the  section  shows  less  characteristic  appear- 
ances ;  but  even  then  the  freshly  forming  tubercles  can  be 
identified.  It  would  seem  as  if  the  identity  of  these  struct- 
ures would  be  admitted  by  common  consent,  supported  as 

*Kbster,  Virch.  Archiv.,  Bd.  xlviii.  ;  Arch,  de  Phys.,  1800,  p.  325. 


48  DISEASES    OF    THE    HIP    JOINT 

it  is  by  the  weightiest  pathological  authority  ;  *  but  so  high 
an  authority  as  Barwell  f  finds  cause  to  argue  that  these 
structures  are  the  result  of  fatty  and  suppurative  degenera- 
tion. His  views,  however,  find  no  acceptance  whatever. 
Similar  masses  of  inspissated  mucus  may,  however,  be  found 
imbedded  in  the  granulations. 

Tubercle  bacilli  are  found  in  a  certain  proportion  of  these 
cases,  and  physiological  evidence  of  their  pathological  iden- 
tity is  abundant.  These  matters  will  be  discussed  later,  and 
for  the  present  it  must  be  accepted  that  the  nature  of  these 
minute  bodies  occurring  in  the  gelatinous  granulations  is 
abundantly  proven  to  be  tuberculous. 

Synovial  membrane  which  has  reached  such  a  degree  of 
purulent  inflammation  as  this  pursues  one  of  two  courses. 
If  matters  go  badly,  the  granulations  melt  down  rapidly  into 
pus  and  take  on  an  erosive  action.  In  their  rapid  career  the 
synovial  membrane  is  destroyed,  and  the  capsule  becomes 
thickened  and  softened,  and  probably  bursts,  letting  out  the 
pus  into  the  periarticular  structures,  constituting  the  com- 
monest form  of  joint  abscess.  The  cartilage  becomes  degen- 
erated and  disintegrates,  exposing  the  hyperaemic  articular 
surfaces  of  the  bones,  which  are  at  once  attacked  by  the  pus 
and  take  on  a  destructive  activity  themselves.  Finally,  what 
was  formerly  a  joint  is  now  amass  of  granulating  and  degen- 
erated tissue,  in  which  the  bare  and  eroded  ends  of  the  bone 
are  loosely  imbedded,  while  sinuses  drain  off  the  pus.  It 
can  be  seen  that  it  is  not  easy  to  set  a  limit  to  the  destruc- 
tive activity  of  such  a  process  as  this. 

If,  on  the  other  hand,  resolution  is  to  take  place  in  such 
a  purulent  synovitis  as  that  described,  the  granulations  be- 
come firmer  and  less  pale,  the  tubercles  cease  to  extend 
and  become  less  frequent.  In  the  granulation  masses  the 
connective  tissue  can  be  seen  by  the  microscope  to  predomi- 

*Bnssaud,  Rev.  Mens,  de  Med.  et  de  Chir.,  1879,  June  10;  Kbnig,  Deutsch.  Arch.  f.  Chir., 
xi.  pp.  317  and  350. 

t  Dis.  of  Joints,  1881 ;  and  Lancet,  Aug.  2,  188.^. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  49 

nate  over  the  cellular  elements,  and  the  secretion  of  pus 
diminishes  in  proportion  to  this  change.  This  is  merely  the 
first  stage  in  the  change  to  fibrous  tissue.  This  will,  in 
cases  where  the  change  has  been  at  all  extensive,  lead  to 
fibrous  contractions  of  the  capsule,  and  to  adhesions  between 
the  joint  surfaces,  impairing  or  obliterating  the  joint  move- 
ment. Recovery  from  chronic  purulent  synovitis  with  per- 
fect joint  mobility  is  only  likely  to  occur  where  the  syno- 
vial membrane  has  been  but  slightly  affected,  because,  if 
granulations  have  once  formed,  they  can  only  be  replaced 
by  scar  tissue,  and  contraction  of  the  surrounding  tissues 
follows  necessarily. 

Such,  in  brief,  are  the  changes  which  occur  in  the  synovial 
membrane  in  chronic  joint  tuberculosis.  It  matters  very 
little  whether  the  changes  originated  in  the  bone  or  the  sy- 
novial membrane,  the  pathological  appearances  in  the  latter 
are  much  the  same,  and  the  results  are  similar. 


Cartilaginous  Changes. 

But  no  marked  degree  of  change  in  the  synovial  mem- 
brane will  have  been  reached  without  affecting  the  cartilage 
of  the  hip  joint  and  the  articular  surfaces  of  the  bones. 

First,  as  to  the  changes  in  the  cartilage.  Primary  inflam- 
mation of  cartilage  is  not  an  affection  which  is  believed  to 
exist  in  tuberculous  joint  disease  ;  and,  although  cases  have 
been  reported  of  so-called  primary  disease  of  the  interverte- 
bral discs,*  and  of  the  cartilage  of  the  knee  f  joint  in  one  in- 
stance, there  is  not,  so  far  as  the  writer  has  searched,  a  single 
authenticated  instance  of  primary  disease  of  the  cartilages  of 
the  hip,  except  in  the  writings  of  twenty  years  ago  recording 
changes  which  are  now  known  to  be  secondary  to  inflamma- 
tion elsewhere. 

*Ogle,  Path.  Soc.  Trans.,  xv.,  1S63 ;  Broca,  Gaz.,  Hebdom.,  1864,  p.  298;  Chassaignac,  Gaz. 
des  Hop.,  1858,  p.  156. 

t  Kocher,  Cent.  f.  Chir.,  Nov.  5,  1S81. 


50  DISEASES    OF    THE    HIP    JOINT 

To  the  eye  the  appearances  which  occur  in  the  cartilage 
in  chronic  purulent  synovitis  are  manifested  by  a  loss  of 
the  blue-white  opalescent  look  which  healthy  hyaline  carti- 
lage possesses.  It  becomes  yellowish,  and  looks  softer  and 
more  succulent  than  it  should  normally.  The  synovial  mem- 
brane has  crept  over  on  to  it  in  places  at  the  edges  ;  and,  if 
an  attempt  is  made  to  detach  it,  it  is  found  adherent,  and,  if 
pulled  off,  may  leave  a  red  and  eroded  surface  of  cartilage 
behind  it.  In  some  places  it  may  tend  to  disintegrate,  and 
to  be  replaced  by  granulations  ;  while  in  others  it  is  cast  off 
in  flakes  or  large  masses  loose  into  the  joint.  Sometimes 
the  whole  cartilage  of  the  head  of  the  femur  may  be  thrown 
off,  or  it  may  hang  in  tags,  or  look  worm-eaten,  or  be  under- 
mined by  granulations.  With  the  destruction  of  the  carti- 
lage, the  ends  of  the  bones  are  exposed  to  the  destructive 
processes  going  on  in  the  joint. 

Microscopically,  the  cartilaginous  changes  are  those  by 
which  cartilage  always  responds  in  inflammatory  conditions. 
The  nuclei  and  the  cells  both  multiply  very  fast,  and  the  hya- 
line substance  tends  to  become  fibrillated.  Fatty  degenera- 
tion '  of  the  cells  ensues;  and  with  it  come  softening  and 
further  fibrillation  of  the  cartilage,  which  lead  to  its  disinte- 
gration. 

The  casting  off  of  large  surfaces  of  cartilage  occurs  chiefly 
in  cases  where  the  disease  is  primarily  osseous  and  shuts  off 
the  nourishment  supply  of  the  articular  cartilage. 

Osseous  CJianges. 

The  changes  which  occur  in  the  bones  are  the  most  im- 
portant and  the  most  significant.  It  will  be  shown  later  that 
the  most  frequent  origin  of  hip  disease  is  in  the  epiphysis  of 
the  head  of  the  femur. 

Specimens  of  beginning  hip  disease  are  very  rare,  so  that 
the  earliest  changes  are  more  a  matter  of  inference  than  of 
observation.     A  hyperasmia  takes  place  in  the  spongy  tissue 


TUBERCULOUS    OSTITIS    OF    THE    HIP  5 1 

about  the  epiphysis,  which  is  followed  by  the  appearance  in 
the  centre  of  this  byperasmic  area  of  a  small  grayish,  translu- 
cent spot,  which  increases  in  size  and  is  surrounded  by  a 
zone  of  hypercemia.  Cases  little  more  advanced  than  this 
have  been  reported  by  Lannelongue.* 

It  is  probable  that  this  stage  of  the  disease  is  caused  by 
an  infection  through  the  blood-vessels,  that  bacilli  or  mi- 
crococci become  heaped  up  in  the  capillary  of  an  Haversian 
canal  and  start  up  an  endarteritis,  which  results  in  a  tuber- 
cle. The  irritation  of  this  process  causes  and  keeps  up  the 
hyperasmia  which  results  in  the  processes  described  as  rare- 
fying ostitis.  That  is,  the  trabeculae  are  absorbed  in  the 
hyperaemic  area  surrounding  the  tubercle,  enlarged  bone 
spaces  are  formed,  and  fatty  degeneration  of  the  bone  cells 
occurs  with  the  transformation  of  their  contents  to  embryo- 
nal or  granulation  tissue. 

The  earliest  stage,  then,  seems  to  consist  of  a  tubercle 
situated  in  an  area  of  hyperaemic,  spongy  bone  tissue  which 
is  undergoing  the  absorption  and  degeneration  which  result 
from  prolonged  hyperaemia. 

The  gray  spot  continues  to  increase,  and  in  its  centre  be- 
comes yellowish,  and  around  it  appear  other  small  gray 
spots,  which  merge  into  it  and  hasten  its  destructive  career. 
Most  often  the  centre  softens  and  breaks  down  into 
pus  ;  but  before  that  it  oftenest  goes  through  a  stage  when 
it  is  filled  with  a  semi-solid,  cheesy  mass,  consisting  of 
detritus,  spicules  of  bone,  amorphous  matter,  and  fat. 

The  active  destruction  goes  on  at  the  periphery  of  this 
nodule,  and  its  growth  takes  place  in  the  direction  of  least 
resistance.  Sequestra  of  varying  size  may  be  found  in  con- 
nection with  these  foci  of  disease.  These  are  caused  by  the 
cutting  off  of  the  vascular  supply  from  some  area  of  bone, 
due  to  the  growth  of  the  tubercles.  At  the  hip  they  are 
likely  to  be  more  extensive  than  elsewhere,  owing  to  the 
fact  that  the  whole  upper  epiphysis  of  the  femur  lies  zvithin 

*  Coxotuberculose.     Paris,  1886. 


52  DISEASES    OF    THE    HIP   JOINT 

the  joint,  and  that  the  main  vessels  enter  on  the  upper  sur- 
face of  the  neck.  It  thus  happens  that  the  blood  supply  of  a 
large  area  may  be  easily  shut  off,  and  this  accounts  for  the 
comparative  frequency  of  necrosis  of  whole  or  part  of  the 
femoral  epiphysis.  This  cannot  be  spoken  of  as  a  common 
condition,  but  it  occurs  often  enough  to  have  attracted  con- 
siderable attention.*  Mr.  Parker  found  this  condition  in  5 
out  of  8  cases,  and  ]^Ir.  Morrant  Baker  in  1 1  out  of  24. 
Air.  Wright,!  who  quotes  them,  finds  this  too  high  a  percent- 
age, and  reports  only  seventeen  sequestra  of  the  femur  in 
100  cases.  Occasionally,  the  necrosis  extends  for  a  short 
distance  into  the  diaphysis. 

To  return  to  the  focus  of  disease,  which  exists  as  a  puru- 
lent or  cheesy  mass  in  the  epiphysis,  it  may  at  this  stage  be 
absorbed,  it  mav  grow  toward  the  periosteum  and  be  dis- 
charged outside  of  the  joint,  or  lastl}^  it  may  break  into  the 
joint  (which  is  probably  the  commonest  course),  and  infect 
that  with  a  purulent  inflammation. 

If  the  conditions  are  favorable  for  its  absorption,  it  be- 
comes more  cheesy  and  dry,  and  remains  as  a  cheesy  mass 
latent  in  the  bone,  still  infected  with  the  bacilli,  but  quies- 
cent until  some  general  or  local  cause  calls  it  into  activity; 
or,  after  becoming  dry  and  cheesy,  it  is  the  seat  of  the  de- 
posit of  lime  salts,  becoming  calcified ;  or,  lastly  and  most 
uncommonly,  the  pus  ma}'  be  absorbed,  leaving  a  cavity 
filled  with  clear  serum.  It  is  not  likely  that  absorption 
occurs  where  the  focus  contains  sequestra  of  any  size. 

It  can  be  seen  from  the  anatomical  conditions  of  the  hip 
joint  that  a  focus  of  disease  in  the  neighborhood  of  the 
epiphysis  of  the  femur  is  much  more  likely  to  invade  the 
joint  in  its  growth  than  to  travel  toward  the  surface  of 
the  bone  outside  of  the  capsule.  It  may  be  mentioned  once 
more  that  the  epiphysis  lies  wholly  within  the  joint.  Never- 
theless, it  does  occur  that  the   enlargement   of  the  tuber- 

*R.  W.  Parker.  CKn.  Soc.  Trans.  iS8o.      t  G.  A.  Wright,  Hip  Disease,  Loudon,  JSS7,  p.  30. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  53 

culous  disease  takes  place  at  times  away  from  the  joint  sur- 
face, and  the  contents  of  the  diseased  area  are  discharged 
externally,  and  the  cavity  heals.  This  is,  of  course,  much 
more  likely  to  happen  where  the  origin  of  the  trouble  is 
in  the  diaphysis  and  in  those  uncommon  cases  where  the 
epiphysis  of  the  great  trochanter  is  the  one  involved. 
When  the  disease  travels  toward  the  surface  of  the  bone, 
the  periosteum  over  it  becomes  thickened  and  soft,  and  a 
slight  or  severe  cellulitis  of  the  neighboring  tissues  occurs. 

This  termination  of  joint  disease  explains  those  cases 
where  slight  hip  disease  is  followed  by  an  abscess,  after 
which  the  symptoms  quickly  subside. 

Finally,  the  most  common  course  of  the  three  is  when  the 
tuberculous  focus  advances  toward  the  joint  cavity.  The 
original  tuberculous  focus  has  broken  down  into  pus,  and  is 
surrounded  by  smaller  tubercles,  which  aid  in  its  destructive 
work  in  melting  down  the  bone.  There  is  no  joint  disease 
at  first.  Volkmann  says  that  "  the  danger  to  the  joint  begins 
with  the  softening  of  the  cheesy  mass."  As  the  inflamma- 
tion of  the  bone  approaches  the  articular  cartilage,  inflamma- 
tion of  the  joint  begins  before  direct  infection  of  the  joint 
from  the  tuberculous  pus  has  occurred. 

From  the  early  resections  of  Volkmann*  and  from  the 
autopsies  of  Lannelongue,  it  would  seem  as  if  the  joint  in- 
flammation originated  by  sympathy  as  well  as  by  direct  in- 
fection. Certainly,  it  has  not  been  uncommon  to  find  a 
degree  of  purulent  synovitis  accompanying  an  osseous  focus 
which  has  not  broken  into  the  joint  and  which  could  only 
have  caused  it  in  some  indirect  way. 

The  synovial  membrane  becomes  inflamed  and  undergoes 
the  changes  described  above,  especially  in  the  neighborhood 
of  the  bone  disease.  The  cartilage  becomes  secondarily  in- 
flamed and  softened  over  the  approaching  focus,  and  the 
way  is  prepared  for  the  entrance  of  the  pus  into  the  joint. 
Generally,  a  small  hole  exists  at  first,  which  becomes  larger 
as  the  disease  advances. 

*  Samml.  Klin.  Vort.,  No.  52. 


54  DISEASES    OF    THE    HIP    JOINT 

When  this  stage  is  reached,  it  is  evident  that  it  matters 
little  whether  the  disease  began  in  the  bone,  the  cartilage, 
or  the  synovial  membrane,  since  all  are  involved  in  the 
destructive  inflammation.  The  mechanism  is  at  hand  for  an 
extensive  and  destructive  inflammation.  In  cases  of  femoral 
disease  the  acetabulum  becomes  secondarily  involved,  and 
with  that  one  finds  a  periosteal  and  fibrous  thickening  on  the 
inner  side  of  the  pelvis  under  it,  which  is  Nature's  effort  to 
prevent  perforation. 

Perforation  of  the  acetabulum,  however,  occurs  in  a  cer- 
tain proportion  of  the  more  serious  cases ;  and  the  head  of 
the  femur  may  be  forced  through  the  bottom  of  the  socket 
into  the  pelvis,  or,  more  commonly,  the  opening  is  only  large 
enough  to  cause  the  formation  of  an  intra-pelvic  abscess,  the 
pus  from  which  may  be  found  discharging  into  the  rectum 
or  involving  the  other  pelvic  viscera.  ]More  commonly  it 
points  in  the  buttock  or  under  the  adductor  tendons.  An 
important  element  to  be  taken  into  account  is  found  in 
the  constant  muscular  contraction  accompanying  hip  disease, 
which  crowds  the  head  of  the  femur  against  the  upper  edge 
of  the  acetabulum,  causing  not  only  wearing  away  of  the 
softened  bone  composing  the  head  of  the  femur  (spoken  of 
as  absorption  of  the  head),  but  also  wearing  away  the  upper 
edge  of  the  acetabulum  and  causing  an  upward  elongation  of 
that  cavity  (spoken  of  often  as  migration  of  the  acetabulum). 

This  results  in  the  malposition  upward  of  the  head  of  the 
femur,  and  the  consequent  shortening  of  the  leg  from  the  al- 
tered relation  of  the  femur  to  the  pelvis.  Real  shortening 
and  atrophy,  as  well  as  retardation  of  growth,  are  to  be  found 
in  the  affected  limb,  which  is  another  element  in  the  produc- 
tion of  the  short  leg  of  hip  disease. 

True  dislocation  of  the  hip  is  very  uncommon  in  hip  dis- 
ease, occurring  only  when  the  changes  affect  the  capsule 
very  extensively. 

Accompanying  the  changes  in  the  spongy  tissue  of  the 
epiphysis,  the  periosteum  of  the  neck  of  the  femur  and  the 


TUBERCULOUS    OSTITIS    OF    THE    HIP  55 

trochanter  becomes  secondarily  involved  and  thickened ;  and 
the  capsule  of  the  joint  becomes  softened  and  often  dis- 
tended by  the  purulent  effusion.  Finally,  it  gives  way,  and 
the  pus  finds  its  way  into  the  periarticular  tissues  to  form  a 
hip  abscess.  Another  source  of  hip  abscess'is  to  be  found  in 
the  formation  and  degeneration  of  an  independent  focus  of 
tubercle  outside  of  the  capsule. 

Even  in  the  milder  cases  of  hip  disease  without  abscess 
formation  there  are  to  be  found  a  condensation  and  infiltra- 
tion of  the  superficial  tissues,  which  are  rarely  mentioned. 

Even  at  the  stage  of  joint  inflammation  just  described,  ab- 
sorption may  occur  and  a  cure  result.  This  comes  about  by 
the  evacuation  or  absorption  of  the  purulent  effusion  and  the 
consolidation  of  the  granulations,  with  their  change  to  con- 
nective tissue,  forming  a  fibrous  anchylosis,  which  may  later 
be  the  seat  of  a  bony  deposit. 

On  the  other  hand,  the  tuberculous  process  may  continue 
to  spread  and  invade  the  more  superficial  tissues  until  they 
have  the  consistency  of  pork.  Many  sinuses  form,  and  the 
destruction  of  the  joint  goes  on,  until  the  patient  dies  of 
exhaustion  or  some  intercurrent  affection. 

Tuberculosis  of  the  other  organs  may  be  found  in  connec- 
tion with  hip  disease,  especially  tuberculosis  of  the  meninges 
and  of  the  lungs.  In  cases  where  the  suppuration  has  been 
long  continued,  amyloid  changes  may  be  found  in  the  liver 
and  intestines. 

It  should  be  said,  in  closing  this  section  of  the  pathology, 
that  the  origin  of  the  disease  may  be  in  single  or  multiple 
foci,  beginning  in  the  cancellous  tissue. 

There  is,  moreover,  a  second  form  of  tuberculous  disease 
of  bone,  which  has  been  left  to  the  end,  to  prevent  confusion  ; 
namely,  the  infiltration  of  a  whole  or  part  of  an  epiphysis 
with  a  tuberculous  deposit.  A  grayish  substance,  soft  and 
semi-translucent,  first  appears  in  the  tissue  of  the  epiphysis, 
in  appearance  like  the  single  focus  of  disease  spoken  of  above. 
This  degenerates  in  spots  into  yellowish,  purulent  material, 


56  DISEASES    OF    THE    HIP    JOINT 

and  soon  pus  forms  everywhere,  and  the  tissue  is  bathed  in 
pus.  This  process  is  more  rapid  and  more  destructive  than 
the  focal  form  mentioned  above.  This  latter  form  was  first 
described  by  Xelaton  under  the  name  of  "  infiltrated  tu- 
bercle," while  the  common  form  was  called  by  him  "encysted 
tubercle." 

To  return  to  the  microscopical  characteristics  of  the  affec- 
tion, and  to  ask  what  evidence  we  have  that  the  process  is  a 
tuberculous  one,  the  evidence  is  threefold,^  (a)  physiological 
(inoculation  experiments),  {b)  histological,  {c)  bacteriological. 

(a)  Inoculation  experiments  will  be  discussed  in  speaking 
of  the  etiology. 

{b)  The  microscopical  appearances  are  those  of  a  typical 
granulating  tuberculosis.  In  the  later  stages  the  type  of 
the  characteristic  structures  is  obscured  by  cheesy  degener- 
ation, but  earlier  one  finds  that  typical  tubercles  with  epi- 
thelioid and  giant  cells  lie  in  the  granulation  tissue.  Later 
thev  lie  in  an  amorphous  mass,  composed  of  bone  spicules, 
fat,  and  detritus  of  all  sorts.  Outside  of  this  area  is  still 
a  zone  of  hyperaemic  bone,  the  pathological  appearances  of 
which  have  been  already  described. 

In  short,  so  far  as  structure  can  establish  the  identity  of 
tubercles,  they  are  present  here. 

(<f)  But  a  more  accurate  criterion  is  to  be  found  in  the  pres- 
ence of  the  bacillus  of  tubercle  in  the  diseased  structures. 
Unfortunately,  the  process  of  finding  them  is  a  difficult  one, 
which  prevents  frequent  search  for  them  and  which  renders  it 
easy  to  overlook  them.  Moreover,  they  are  present  in  small 
numbers  at  that  stage  of  bone  tuberculosis  which  comes  to 
examination,  so  that  their  absence  in  any  given  examination 
cannot  count  for  very  much  unless  the  searcher  is  a  person 
of  much  technical  skill  who  has  failed  to  find  them  on  re- 
peated examination.  It  has  been  customary  to  use  a  modifi- 
cation of  Ehrlich's  method. 

To  illustrate  the  difficulty  of  finding  them,  one  may  cite 
the    experience  of    Schuchardt    and  Krause,  who   examined 


TUBERCULOUS    OSTITIS    OF    THE    HIP  5/ 

some  forty  cases  of  scrofulous  and  fungous  joint  disease  at 
Volkmann's  clinic,  in  all  of  which  they  were  able  to  find  the 
bacilli ;  but  in  one  instance  it  Vv^as  necessary  to  make  twenty 
sections  to  find  two  bacilli.  Some  other  observers  have  not 
been  able  to  find  bacilli  in  so  large  a  proportion  of  cases. 
Kanzler,*  in  15  cases,  found  them  present  in  only  8  ;  and 
Muller,t  in  some  40  cases,  in  most  of  which  he  used  the  pus, 
found  cases  where  he  was  unable  to  demonstrate  the  pres- 
ence of  the  bacilli  by  any  process  to  which  he  resorted.  The 
latest  observers  J  have  been  able  to  find  bacilli  in  nearly  all 
cases,  which  is  a  contrast  to  the  experience  of  the  early  in- 
vestigators, such  as  Koch.  § 

Konig  reported  an  analysis  of  71  cases  of  hip  disease,  in 
6'J  of  which  the  tuberculous  character  of  the  process  was 
unmistakable. 

Having  discussed  at  length  the  changes  which  occur  in 
bone,  cartilage,  and  synovial  membrane  in  hip  disease,  it 
becomes  a  matter  of  interest  to  investigate  the  relative  fre- 
quency of  primary  bone  and  synovial  affections. 

In  a  word,  it  may  be  said  that  modern  pathology  has  es- 
tablished the  fact  that  epiphyseal  ostitis  is  the  first  change 
in  the  great  majority  of  cases,  especially  in  children  ;  while 
synovitis  is  relatively  more  common  in  adults.  This  state- 
ment will  be  substantiated  by  a  detailed  analysis  later. 

The  question  of  the  seat  of  the  primary  disease  in  hip 
joint  disease  has  been  the  subject  of  very  warm  discussion 
during  the  past  fifty  years,  and  it  is  to-day  more  a  matter 
of  historical  than  of  practical  interest.  Mr.  Wright,  in  his 
admirable  book  on  Hip  Disease,  gives  a  complete  summary 
of  the  phases  and  changes  of  opinion  in  the  matter.  ||  Origi- 
nally, the  disease  was  thought  to  be  of  synovial  origin,  and 
Billroth  and    Sayre    still    represent    that    opinion.       Brodie, 

*  Berl.  Kl.  Wchsft.,  1884,  2,  January  14.  t  Cent.  f.  Chir.,  18S4. 

tPark,  Med.  Press,  W.  N.  York,  January,  1S87. 

§  Koch,  Fortsch.  d.  Med.,  1883,  g,  Bd.  i.  p.  277. 

II  G.  A.  Writ;ht,  on  Hip  Disease  in  Childhood.    London,  1887. 


58  DISEASES    OF    THE    HIP    JOINT 

although  realizing  the  fact  that  many  cases  of  the  disease 
began  in  the  bone  or  synovial  membrane,  was  an  advocate  of 
the  frequency  of  a  primary  affection  of  the  cartilage  as  the 
real  trouble,  in  which  very  few  writers  have  followed  him. 
Ashton  Key  originated  the  theory  that  the  disease  began  in 
the  ligamentum  teres  ;  and  Adams,  Holmes,  Owen,  and  Coul- 
son  are  advocates  of  the  ligamentous  origin  of  the  disease. 

Among  the  surgeons  who  believe  in  the  primarily  osseous 
origin  of  hip  disease  in  the  great  majority  of  all  cases  may 
be  mentioned  Barwell,  Bryant,  Gross,  Parke,  Annandale, 
Marsh,  Gibney,  Konig  and  Volkmann  as  representative  of 
nearly  all  German  writers,  and  Lannelongue.  The  evidence 
in  favor  of  this  view  will  show  on  what  a  strong  basis  it  rests. 

Konig  found  in  yi  cases  of  hip  disease  6y  osseous  in  ori- 
gin. Mr.  G.  A.  Wright,  as  the  outcome  of  his  experience  in 
lOO  excisions,  believes  that  "the  disease  begins  almost  invari- 
ably in  the  bone."  Gibney  states  his  belief  that  in  children 
under  eight  years  of  age  chronic  articular  ostitis  is  the  com- 
mon lesion.  Miiller,  in  6i  hip  excisions,  found  in  47  cases 
that  the  disease  clearly  began  in  the  bone,  in  3  in  the  syno- 
vial membrane,  while  in  1 1  the  changes  were  so  far  advanced 
that  it  was  not  possible  to  state  accurately  where  it  origi- 
nated.* 

Volkmann,!  as  the  outcome  of  his  enormous  experience  in 
the  resection  of  joints,  expresses  the  opinion  that  fungous 
joint  begins  usually  (and  always  in  children)  as  a  localized 
ostitis.  This  is  more  the  rule  in  hip  disease  than  in  the 
case  of  the  other  joints,  as  is  shown  by  the  table  of  Miiller, 
analyzing  232  preparations  of  tuberculous  joints  :  — 

Bony  origin.  Syfiovial  origin.  Indefinite. 

Hip, 69  33  16 

Knee,      ....     47  3  11 

Elbow,    ....     42  10  I 

*  Quoted  by  Konig,  Die  Tub.  der  Knocheii  u.  Gelenk. 
t  Samml.  Kl.  Vtrge.,  Nos.  i6S  and  i6g. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  59 

The  evidence  for  primary  ostitis  as  the  cause  is  strength- 
ened by  most  of  the  early  autopsies.  The  four  early  au- 
topsies of  Lannelongue  have  been  already  alluded  to,  and 
demonstrate  this  very  clearly.  Gibney,*  in  his  book,  has 
reported  some  early  autopsies ;  and  the  case  reported  by 
Fricke  f  is  a  well-known  one.  The  reports  of  early  autop- 
sies are  so  few  that  the  above  list  represents  all  that  are 
known   to  the  writer. 

One  autopsy,  however,  made  fairly  early  in  the  disease, 
should  be  mentioned  as  perhaps  demonstrating  the  occa- 
sional occurrence  of  the  disease  primarily  in  the  synovial 
membrane  and  the  ligamentum  teres.  It  was  reported  by 
Drs.  Willard  and  Shakespeare,  and  had  occurred  in  a  child 
where  the  disease  had  existed  a  year,  and  who  died  of  tuber- 
cular meningitis.  Synovial  changes  were  more  marked  than 
the  osseous,  but  the  case  is  open  to  the  criticism  made  by 
Gibney, —  that  the  patient  had  been  under  efficient  treat- 
ment, and  the  osseous  changes  may  have  been  retrograding.  J 

Assuming,  then,  that  the  osseous  origin  of  the  disease  is 
fairly  demonstrated,  it  becomes  of  importance  to  inquire  into 
the  relative  frequency  of  femoral  and  acetabular  ostitis.  This 
is  not  a  distinction  which,  in  the  opinion  of  the  writer,  can 
be  made  in  most  cases  during  life,  although  the  contrary  is 
asserted  by  many  authors,  and  the  only  reliable  data  must  be 
obtained  hy  post-mortem  evidence  and  from  excisions.  Rec- 
tal examination  may  demonstrate  a  thickening  of  the  inner 
side  of  the  pelvis  over  the  bottom  of  the  acetabulum,  but 
that  does  not  prove  primary  disease  of  the  acetabuluhi. 

Mr.  Wright,  in  his  lOO  cases  of  excision,  found  lo  where 
he  thought  that  the  acetabulum  was  primarily  diseased.  At 
operation,  however,  it  was  superficially  diseased  in  49  cases 
(and  these  were  not  particularly  late  cases),  it  was  perforated 
in   16    instances,  it  contained    sequestra  twenty-two    times, 

*  Gibney,  Diseases  of  the  Hip.    New  York,  1884. 

t  A.  B.  Judson,  N.  Y.  Med.  Jour,  and  Obst.  Review,  July,  1882. 

%  Boston  Med.  and  Surg.  Journal,  1880. 


60  DISEASES    OF    THE    HIP    JOINT 

while  in  only  ten  was  it  noted  as  being  healthy.  Certainly, 
in  the  cases  of  excision  coming  under  the  writer's  observation 
(all  being  late  cases),  the  acetabulum  has  always  been  found 
seriously  diseased  along  with  the  femur, 

Habern  has  analyzed  132  of  Volkmann's  hip  joint  exci- 
sions. Of  these  he  found  a  caseous  focus  of  the  acetabulum 
in  50,  in  23  a  focus  of  the  head  of  the  femur,  in  7  there  were 
such  foci  in  both  femur  and  acetabulum,  and  in  29  cases  the 
changes  were  so  far  advanced  that  the  original  seat  of  the 
disease  could  not  be  stated.* 

This  is  not  in  accord  with  the  common  opinion,  although 
figures  are  not  obtainable,  and  it  must  be  noted  that  Habern 
is  a  partisan  strongly  in  favor  of  the  acetabular  theor)'-. 

The  general  consensus  of  opinion  locates  the  origin  of 
most  cases  in  the  epiphysis  of  the  femur. 


The  Etiology  of  Hip  Disease. 

The  knowledge  of  the  pathology  of  bone  tuberculosis  may 
be  in  an  unsatisfactory  condition,  but  it  far  surpasses  in  ac- 
curacy and  completeness  the  sum  of  all  that  can  be  said  with 
regard  to  the  etiology  of  the  affection. 

Formerly  the  writers  on  the  etiology  of  hip  disease  could 
be  classified  into  two  schools, —  those  who  believed  in  a 
constitutional  cause  for  the  affection  and  those  who  would 
find  the  cause  in  a  local  trauma.  Late  years  have  tended  to 
bring  forward  those  who  believe  that  the  disease  is  oftenest 
the  result  of  both  causes. 

It  would  be  hard  to  find  a  better  introduction  to  this  vexed 
question  than  the  mention  of  the  classical  experiments  of 
Schiiller, -which  have  done  so  much  to  furnish  it  with  a  firm 
scientific  basis. 

Guinea  pigs  and  dogs  were  rendered  tuberculous  by  the 
inhalation  of  solutions  containing  tuberculous  detritus  from 

*Cent.  f.  Chir. ,  iSSi,  April  2. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  6l 

diseased  lungs,  etc.,  with  occasional  injection  into  their  lungs 
of  similar  solutions.  The  knee  joint  of  each  animal  was 
then  wrenched  or  bruised,  and  in  the  great  proportion  of  all 
the  cases  a  typical  chronic  tuberculous  synovitis  of  that 
joint  occurred,  while  similar  injuries  to  healthy  animals 
caused  no  joint  disease,  and  nothing  beyond  a  temporary 
strain.*  These  experiments  are  accepted  as  conclusive  by 
all  writers  except  Barwell,  who  finds  fault  with  them  on  very 
insufficient  grounds. f 

The  recognition  of  hip  disease  as  a  tuberculous  affection 
tended  to  weaken  the  cause  of  those  who  advocated  trauma- 
tism as  the  chief  cause  of  the  disease,  and  of  later  years 
their  number  has  diminished  steadily.  The  advocates  of 
traumatism  are  Sayre,  Agnew,  Bauer,  Adams,  and  Petit ;  and, 
at  the  time  when  these  writers  were  most  active,  the  true 
pathology  of  hip  disease  was  but  little  known.  Sayre's 
theory,  that  the  traumatism  caused  a  blood  blister  in  the 
joint  and  a  consequent  joint  inflammation,  is  not  tenable  in 
the  light  of  the  pathology  of  to-day. 

The  presence  of  the  tubercle  bacillus  in  the  tissues,  and 
the  whole  weight  of  modern  opinion,  then,  are  opposed  to 
considering  traumatism  as  more  than  an  exciting  cause  of 
hip  disease. 

To  consider  somewhat  in  detail  the  influence  of  trauma- 
tism and  heredity  as  causes  of  hip  disease. 

Traumatism. —  All  statements  of  the  parents,  to  whatever 
class  of  society  they  may  belong,  tend  to  credit  the  disease 
to  some  accident.  Not  only  does  this  seem  to  them  more 
reasonable,  but  the  supposition  of  an  hereditary  cause  ren- 
ders them  in  a  measure  responsible  for  the  state  of  affairs, 
and  the  disposition  is  very  strong  to  credit  the  disease  to 
some  post-natal  cause  rather  than  to  allow  the  imputation 
to  rest  on  them.  Consequently,  the  figures  in  favor  of  trau- 
matism are  more  likely  to  overstate  than  under  state  the 
truth. 

*Cent.  f.  Chir.,  1878,  v.  t  Lancet,  Aug.  2,  1884. 


62  DISEASES    OF    THE    HIP    JOINT 

Certain  cases  of  hip  disease  develop  a  few  months  or  a 
few  weeks  after  accidents,  such  as  falls,  wrenches,  etc.  The 
proportion  of  cases  beginning  in  this  way  is  variously  stated. 
Konig  has  found  a  traumatic  history  in  about  50  per  cent,  of 
his  cases,  which  represents  an  average  estimate.  Gibney 
found  42  per  cent,  traumatic.  Taylor  attributed  53  per  cent, 
to  injury,  while  Albrecht  presents  the  smallest  estimate,  one- 
sixth. 

The  effect  of  traumatism  in  healthy  children  has  been  in- 
vestigated to  a  certain  extent.  Gibney  observed  845  chil- 
dren affected  with  spinal  paralysis  (a  class  of  children  who 
are  particularly  liable  to  falls),  and  found  only  4  cases  of 
joint  disease.  And  Roser,*  observing  100  children  at  Mar- 
burg with  fractured  elbows,  found  no  case  of  joint  disease 
following  the  injury.  A  personal  case  of  the  writer's  may 
be  of  interest  in  this  connection.  A  boy  of  twelve,  with 
tuberculous  disease  of  the  right  shoulder,  fell  and  fractured 
the  left  elbow.  The  fracture  pursued  the  usual  course  for 
about  six  or  eight  weeks,  when  the  signs  of  joint  disease  ap- 
peared, and  have  since  progressed. 

The  general  opinion  is  that  in  about  half  of  the  cases  a 
traumatic  history  can  be  obtained.  It  is  easy  to  see  how 
this  may  result  in  joint  disease.  From  a  severe  fall  or  in- 
jury there  is  likely  to  result  an  extravasation  of  blood  in  the 
cancellous  tissue  of  the  bone ;  and  in  certain  instances,  in- 
stead of  being  absorbed,  this  may  become  the  seat  of  degen- 
erative inflammation.  Konig  says,  "  There  are  cases  where 
the  swelling  from  the  fall  merges  into  the  tuberculous  swell- 
ing." t 

The  mechanism  of  the  production  of  the  local  trouble  is 
thus  accounted  for,  and  it  is  evident  that  in  half  the  cases 
an  accident  is  associated  with  the  beginning  of  the  disease. 
Let  us  inquire  further  in  what  class  of  children  such  acci- 
dents produce  hip  disease. 

*Roser,  Berl.  Klin.  Wchsft.  t  D.  Zeitsch.  f.  Chir.,  1879,  xi. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  6^ 

Heredity. — In  discussing  the  influence  of  hereditary  tuber- 
culosis on  the  occurrence  of  hip  disease,  the  words  scrofula 
and  scrofulosis  are  much  used,  and  rather  indefinitely.  Hip 
disease  is,  moreover,  often  classed  as  a  scrofulous  joint  dis- 
ease ;  and  this  may  be  as  good  a  place  as  any  to  define  the 
word  as  it  is  used  now.  Dr.  Peters  scarcely  overstates  the 
situation  in  saying  that  those  who  do  not  recognize  the  iden- 
tity of  tuberculosis  and  scrofulosis  are  "  such  surgeons  at 
home  and  abroad  who  do  not  perhaps  enjoy  the  privileges 
of  closely  following  the  rapid  advance  of  pathological  inves- 
tigation." *  The  question  is  discussed  at  length  by  Mr. 
Treves,!  and  other  references  are  given. |  In  this  essay  the 
word  scrofulous  will  not  be  used,  but  in  its  place  the  term 
tuberculous. 

It  has  been  definitely  settled  that  tuberculosis  as  such 
can  be  transmitted  from  the  parents  to  the  foetus.  Lan- 
douzy  and  Martin  took  an  apparently  healthy  foetus  of  six 
and  one-half  months  born  of  a  phthisical  mother,  and  a  bit 
of  its  lung  caused  general  tuberculosis  when  put  into  a 
guinea  pig's  stomach,  and  inoculations  from  that  animal 
were  carried  through  five  animals.  Blood  from  a  similar 
foetus  caused  general  tuberculosis  in  another  guinea  pig. 
One  of  the  tuberculous  guinea  pigs  gave  birth  to  a  litter, 
apparently  healthy,  but  the  inoculation  of  pieces  of  its  liver 
and  kidneys  caused  general  tuberculosis  in  other  guinea 
pigs ;  and  semen  from  one  of  the  tuberculous  guinea  pigs 
was  taken  by  a  carefully  sterilized  needle,  and  inoculated 
into  other  guinea  pigs,  infecting  them  with  general  tubercu- 
losis. 

Practically,  one  finds  a  history  of  inherited  tuberculosis 
in  a  very  large  proportion  of  all  cases  ;  yet  this  is  likely  to 
fall  short  of  the  truth  for  much  the  same  reasons  that  the 
traumatic    histories   are   likely  to  exceed  it.     Hospital   pa- 

*  Canad.  Pract.,  iSgo.  t  Manual  of  Surgery. 

+  Howard  Marsh,  Diseases  of  Joints,  p.  7  ;  Hueter,  Gelenkrankheiten,  and  D.  Arch,  f,  Chir. , 
1879,  xi.;  Modigliano,  Deutsch.  Med.  Ztung.,  Sept.  ig,  1890. 


64  DISEASES    OF    THE    HIP    JOINT 

tients,  from  whom  most  statistics  are  necessarily  obtained, 
are  notoriously  unreliable  as  to  the  life  history  of  their 
relatives  and  their  progenitors ;  and,  moreover,  they  are 
stronglv  inclined  to  throw  their  influence  in  favor  of  trau- 
matism. Consequently,  such  statistics  cannot  be  regarded 
as  more  than  approximate. 

Gibney  *  has  been  the  most  active  investigator  on  the 
side  of  heredity;  and  he  is  a  believer  in  heredity,  or  an 
"acquired  diathesis,"  as  a  well-nigh  indispensable  cause.  In 
596  cases  of  chronic  joint  disease  affecting  various  joints,  he 
was  only  able  to  find  one  case  where  there  was  not  "an 
hereditarv  or  acquired  diathesis."  He  found  tubercular 
disease  of  one  or  both  parents  in  68-}-  per  cent,  and  an 
acquired  diathesis  in   30+  pei"  cent.  more. 

In  401  cases  of  hip  disease  from  the  Alexandra  Hospital 
reports,  35  per  cent,  were  classed  as  traumatic,  and  24  per 
cent,  had  a  history  of  tuberculous  disease  in  one  or  both 
parents.!  C.  Fayette  Taylor  1:  analyzed  845  cases  of  Pott's 
disease  in  this  regard.  He  found  34  per  cent,  where  there 
was  scrofulous  or  tuberculous  disease  in  the  parents. 

Bone  tuberculosis  is  not  often  transmitted  from  parent 
to  child,  as  Bollinger  §  recently  found  in  an  investigation  of 
250  patients  with  bone  tubercle.  In  these  he  found  a  family 
history  of  phthisis  very  common,  however. 

It  must  be  evident  from  these  figures  that  a  history  of 
tuberculosis  in  one  or  both  parents  exists  in  a  large  propor- 
tion of  all  cases  of  hip  disease.  Gibney  seems  to  take  ex- 
treme ground  in  assuming  that  an  hereditary  or  acquired 
diathesis  can  always  be  established.  It  comes  into  the 
experience  of  most  surgeons  from  time  to  time  to  see  the 
robust  children  of  healthy  parents  where  hip  disease  follows 
some  slight  injury,  and  where  the  bone  disease  is  the  only 
evidence  of  tuberculosis  which  is  demonstrable. 

*  Gibney,  Strumous  Element  in  Joint  Dis.,  X.  Y.  M.  J.,  1S77.  Jul}'. 

t  Croft,  Trans.  Clin.  Soc,  London,  xiii. 

JGerman  Trans,  of  "The  Mechan.  Treat,  of  Pott's  Dis." 

§  Cent.  f.  Chir.,  i88g,  35,  p.  609. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  65 

Since  the  fall  or  the  wrench  is  not  capable  of  introducing 
into  the  circulation  the  bacilli  which  are  found  after  it. 
There  is  strong  presumptive  evidence  in  favor  of  the  theory 
that  trauma  only  causes  hip  disease  in  cases  predisposed  to 
tuberculosis  or  infected  by  it.  Shaffer  states  the  question 
very  fairly  in  saying  "  experience  proves  that  traumatism 
excites  only  acute  disease,  as  a  rule.  In  those  constitutions 
strong  enough  to  resist  and  repair  the  injury  these  acute 
troubles  soon  subside.  Under  reverse  circumstances  they 
are  apt  to  be  followed  by  a  chronic  form  of  inflammation, 
which  may  perhaps  end  in  suppuration."  *  The  weightiest 
German  authority  may  be  quoted  to  the  same  effect :  "In- 
dividuals with  fungous  joint  disease  spring,  practically  with- 
out exception,  from  families  in  which  scrofula  and  tubercle 
are  hereditary."  f 

Bad  surroundings,  insufficient  food,  exhausting  illnesses, 
and  the  like  seem  to  work  in  the  same  direction  as  heredity 
in  rendering  children  less  resistant,  and  predisposing  them 
to  tubercular  disease.  It  is  to  such  cases  that  Gibney  ap- 
plies the  term  of  "  acquired  diathesis." 

T/ie  Influence  of  tJie  Exanthemata. —  Certain  of  the  acute 
diseases  of  childhood  are  to  be  recognized  as  important  fac- 
tors in  the  causation  of  hip  disease, —  notably,  measles,  scar- 
let fever,  and  diphtheria,  more  rarely  pneumonia  and  typhoid 
fever.  Croft  estimates  that  7  per  cent,  of  chronic  joint 
disease  in  children  is  due  to  these  causes.  Certainly,  it 
is  very  common  to  find  the  beginning  of  the  joint  disease 
associated  with  the  convalescence  from  one  of  these  affec- 
tions. Nothing  but  conjecture  can  be  presented  to  account 
for  this  state  of  affairs. 

These  are  the  chief  factors  in  the  causation  of  tuberculous 
joint  disease :  an  inherited  or  acquired  tendency  to  tuber- 
culosis in  most  cases  as  the  predisposing  cause,  with  a  history 
of  local  injury  in  about  half  of  the  cases.  In  some  cases,  one 
of  the  exanthemata  seems  to  be  accountable. 

*  American  Clinical  Lectures,  vol.  iii.  p.  141. 
t  Volkmann,  Samml.  Kl.  Vrtrge.,  p.  52. 


66  DISEASES    OF    THE    HIP    JOINT 

Phimosis  as  a  Cause  of  Hip  Disease. — -  Some  mention 
should  be  made  of  this  condition,  which  was  at  one  time 
much  advocated  as  a  cause  of  hip  disease.  Dr.  Parke  demon- 
strated the  very  common  occurrence  of  phimosis  in  healthy 
boys  by  the  examination  of  150.  In  25.5  per  cent,  of  these 
retraction  of  the  foreskin  was  not  possible,  in  23.5  per  cent, 
adhesions  were  present  all  around  the  glans,  in  31.4  per 
cent,  partial  adhesions  were  present,  while  in  only  19.5 
per  cent,  was  complete  retraction  of  the  prepuce  possible.* 

Barvvell,  finding  83  per  cent,  of  children  with  hip  disease 
affected  with  some  phimosis,  concluded  that  it  was  a  cause  of 
hip  disease  ;  but  comparison  with  Parke's  figures  shows  that 
this  proportion  was  about  normal.  Wright  examined  63 
cases,  and  found  that  in  hip  disease  6^  per  cent,  had  phimosis, 
while  of  the  others  only  50  per  cent,  had  it ;  but  the  figures 
are  too  few  for  generalizations. 

In  short,  there  is  as  yet  very  little  evidence  to  point  to 
phimosis  as  a  cause.  It  is  a  very  bad  state  of  affairs,  and 
causes  much  peripheral  irritation,  and  perhaps  incontinence, 
with  often  deterioration  of  the  general  health  ;  but  much 
more  evidence  is  needed  to  connect  it  with  hip  disease. 

Age. —  Tubercular  joint  disease  is  pre-eminently  an  affec- 
tion of  early  childhood.  The  rich  vascular  supply  of  the  juxta- 
epiphyseal  regions  during  ossification,  the  instability  of  the 
tissues,  and  the  constantly  occurring  slight  traumatism,  all 
unite  in  rendering  children  the  most  frequent  victims  of  this 
form  of  disease.  As  one  might  decide  a  priori,  the  time  of 
greatest  susceptibility  would  naturally  be  between  the  ages 
of  three  and  nine.  Where  disease  has  begun,  as  Mr.  Marsh 
has  pointed  out,  there  ensues  an  active  period  of  disease, 
extending  from  two  to  five  or  six  years,  so  that  in  a  sense 
tuberculosis  of  bone  is  to  be  regarded  as  a  self-limited  dis- 
ease. 

*  Chicago  Medical  J.  and  Examiner.  1880. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  6/ 

Wright  tabulated  619  cases  of  hip  disease,  as  follows  :  — 

Under  6  years, 40 

From  6  to  10  years, .  1 10 

From  10  to  15  years, 129 

From  15  to  20  years, 66 

From  20  to  25  years, 39 

From  25  to  30  years, 17 

Over  30  years, 17       418 

And  in  another  group  were  classed  the  others 

Under  2  years, 28 

From  2  to  5  years, 62 

From  5  to  10  years, 81 

From  10  to  14  years, 30       201 

619 

Bryant  tabulated  360  cases,  as  follows  :  — 

Under  4  years, 126 

From  5  to  lo  years, 97 

From  10  to  20  years,       86 

From  20  to  30  years,        27 

From  30  to  40  years,       13 

Over  40  years, 11 

360 

At  the  New  York  Orthopedic  Dispensary  from  1884-86 
were  treated  1,178  cases  of  hip  disease,  the  ages  of  which 
were  as  follows  :  — 

Under  3  years, 115 

From  3  to  5  years, 316 

From  5  to  10  years, 509 

From  10  to  15  years, 140 

From  1 5  to  20  years, 47 

Over  20  years, 51 

1^78 


68  DISEASES    OF    THE    HIP    JOINT 

If  to  these  groups  are  added  Gibney's  860  cases  and  365 
reported  by  Sayre,  there  are  3,382  cases  of  hip  disease,  2,806 
of  which  occurred  before  the  age  of  fifteen. 

Se.i: — Boys  are  slightly  more  liable  to  have  hip  disease  than 
girls  are,  from  which  the  advocates  of  phimosis  have  drawn 
many  conclusions.  It  seems  easily  enough  accounted  for, 
however,  by  the  fact  that  boys  lead  a  much  more  active  life 
and  are  more  liable  to  rough  use  and  all  sorts  of  traumatism. 
Of  Wright's  619  cases,  371  were  boys  ;  and  Holt  collected  for 
Gibney  2,307  cases  of  hip  disease,  and  found  1,178  boys 
and  1,129  girls. 

Inoculation  Experiments. —  Certain  facts  with  regard  to  the 
etiology  of  tuberculous  joint  disease  have  been  established 
by  experiment,  which  have  a  bearing  more  or  less  practical 
upon  the  subject  under  discussion. 

{a)  It  has  been  proved  that  cultures  of  the  tubercle 
bacillus  or  detritus  containing  tubercular  material  (whether 
from  scrofulous  glands,  phthisical  lungs,  or  fungous  joint 
cavities)  are  capable  of  producing  general  tuberculosis  if 
introduced  into  the  system,  or  tuberculous  joint  disease  if 
introduced  into  the  joints.*  The  most  careful  and  most 
recent  experiments  are  those  of  Parllovski.f  who  made  pure 
cultures  of  the  tubercle  bacilli  in  peptonized  glycerine,  and 
injected  these  into  the  knee  joints  of  guinea  pigs.  The 
animals  were  killed  at  intervals  of  from  12  hours  to  8  weeks, 
and  the  changes  noted.  In  12  hours  the  bacilli  would  have 
found  their  wav  into  the  connective  tissue  and  white  blood 
corpuscles,  and  their  progress  along  the  lymphatics  could  be 
observed. 

{b)  The  injection  of  inorganic  material  not  containing 
tuberculous  matter  in  either  the  joints  or  the  general  circu- 
lation! does  not  cause  tuberculosis. 

*  Hueter,  D.  Arch.  £.  Chir.,  1879,  xi.  317;  Tnconi,  Baumgarten's  Jahresberich.,  ii.  p.  229, 
1886;  N.Y.  Med.  Ass'n  Report,  ii.  p.  331;  Cent.  f.  Chir.,  1878,  v.  p.  43. 

t  VVratsch.,  St.  Petersburg,  v.  10,  p.  635,  and  London  Lancet,  Nov.  2,  1S90. 

%  Sternberg,  N.Y.  Med.  Journal,  1884,  p.  325. 


TUBERCULOUS    OSTITIS    OF    THE    HIP  69 

(c)  It  is,  however,  probable  that  the  bacilli  most  often 
reach  the  joint  through  the  circulation.  Miiller  injected 
into  the  femoral  artery  of  16  rabbits  tubercular  material, 
with  negative  results.  Where  such  material  was  injected 
into  the  crural  artery  from  which  the  nutrient  arteries  arise, 
in  some  of  the  animals  tuberculous  bone  disease  occurred. 
Finally,  the  material  was  injected  directly  into  the  nutrient 
arteries;  and  in  the  case  of  goats  most  of  those  injected 
showed  signs  of  typical  tuberculous  joint  disease  beginning 
from  a  focus  deposited  in  the  epiphysis.*  Triconi,  injecting 
tuberculous  material  directly  into  the  diaphyses  and  epi- 
physes of  bones,  started  up  bone  disease  in  type  like  hip 
disease,  with  occasional  synovitis.! 

To  the  writer's  mind  the  only  tenable  supposition  in  the 
matter  is  that,  where  trauma  causes  joint  disease  of  a  tuber- 
culous type,  it  m?ist  be  assumed  that  tubercle  bacilli  were 
present  in  the  circulation,  and  were  merely  localized  by  the 
injury. 

That  nearly  all  hip  disease  is  tubercular  in  type  is  shown 
by  all  the  pathological  knowledge  at  our  command.  Hence 
the  writer  would  advocate  the  opinion  that  hip  disease 
occurs,  as  a  rule,  only  in  those  who  have  an  hereditary  or 
acquired  tendency  to  tuberculosis,  and  that  in  a  large  pro- 
portion of  these  cases  an  accident  is  the  exciting  cause  of 
the  disease,  but  that  hip  disease  apparently  of  a  tubercular 
type  occurs  at  times  in  children  who  present  every  appear- 
ance of  perfect  health. 

*  Cent.  f.  Chir.,  1886,  xiv.  t  Triconi,  loc.  cit. 


JO  DISEASES    OF    THE    HIP    JOINT 


Chapter  VI. 
THE  TREATMENT   OF    HIP   DISEASE. 

The  treatment  of  hip  disease  is  necessarily  either  (I.) 
rnecJianical  or  (II.)  operative. 

(I.)  Mechanical  treatment  can  be  subdivided  for  practical 
purposes  into  three  well-marked  methods,  although  combina- 
tions of  these  methods  exist  :  — 

{a)  Protection  methods. 

{U)  Fixation  methods. 

(r)  Traction  methods. 

(II.)  Operative  treatjuent  can  be  discussed  as  a  whole,  and 
will  be  considered  after  the  discussion  of  the  various  me- 
chanical methods. 

I.     The  Mechanical  Treatment  of  Hip  Disease. 

{a)  By  Protection. 

The  treatment  of  hip  disease  by  protecting  the  diseased 
joint  from  the  jar  and  weight  in  walking  without  the  use  of 
apparatus  is  but  little  different  from  the  treatment  by  expec- 
tancy. In  its  simplest  form  the  latter  was  practised  by  the 
late  Dr.  James  Knight,  of  New  York,  surgeon  to  the  Hospi- 
tal for  the  Ruptured  and  Crippled  :  and  his  views  are  set 
forth  in  his  book,  "  Orthopsedia."  Counter-irritants  were 
applied  to  the  skin  over  the  hip,  the  children  were  kept 
rather  more  quiet  than  before  coming  under  treatment,  and, 
if  walking  became  excessively  painful,  they  were  allowed 
crutches.  This  treatment  was  followed  out  in  a  very  large 
clinic ;  and  the  large  number  of  active  cases  of  the  disease 
to  be  seen  there,  who  were  not  uncomfortable  to  any  degree, 


THE    TREATMENT    OF    HIP    DISEASE  /I 

demonstrated  the  fact  that  hip  disease,  left  to  itself,  is  not 
always  painful.  With  Dr.  Knight's  death,  the  only  believer 
in  the  expectant  treatment  of  hip  disease  passed  away. 

The  method  known  as  the  physiological  method,  or  Hutch- 
inson's treatment,  is  still  pursued  in  certain  parts  of  the 
country  where  apparatus  is  not  attainable.  In  the  cities 
no  one  of  experience  uses  it,  nor  is  it  in  any  degree  trust- 
worthy. It  was  proposed  some  years  ago  by  the  late  Dr. 
James  Hutchison,  of  Brooklyn,*  and  consists  simply  in  put- 
ting a  high  sole  on  the  well  foot  and  having  the  patient  go 
about  on  crutches,  allowing  the  diseased  leg  to  swing.  In 
sitting  down  or  getting  up,  the  diseased  joint  is  unpro- 
tected and  subject  to  jar  and  strain  ;  and  the  weight  of  the 
leg  is  in  no  way  to  be  considered  as  a  traction  force  to  coun- 
teract the  muscular  irritability.  Subluxation  and  elevation 
of  the  trochanter  are  very  likely  to  occur,  as  well  as  malposi- 
tions of  the  diseased  limb.  These  are  the  obvious  objections 
to  the  treatment,  as  borne  out  by  practical  experience.  The 
method  is  of  benefit  in  so  far  as  it  protects  the  joint  from 
the  jar  of  walking,  and  in  mild  cases  is  somewhat  better 
than  no  treatment  at  all. 

Methods  of  treatment  which  combine  protection  with 
fixation  or  traction  will  be  considered  under  these  headings. 
The  treatment  of  convalescent  hip  disease  is  a  treatment  by 
protection,  which  will  be  considered  later. 


I.     Mechanical  Treatment. 

{b)  By  Fixation. 

Of  all  the  methods  which  aim  at  curing  hip  disease  by 
fixation  of  the  diseased  joint,  the  most  efficient  is  that  asso- 
ciated with  the  name  of  the  late  Mr.  H.  O.  Thomas,  of  Liv- 
erpool.f      It  is,  as  a   rule,  the  apparatus    used  by  English 

*  American  Journal  of  Medical  Sciences,  July,  1877. 
t  New  York  Medical  Record,   Sept.  15,  188S. 


72 


DISEASES    OF    THE    HIP   JOINT 


orthopedic  surgeons  ;  and  in  Dr.  Ridlon,  of  New  York,  it  has 
found  an  ardent  advocate.  It  is,  however,  but  little  used  in 
America.* 

TJie  TJw)nas  Splint. 

This  splint  consists  in  a  bar  of  soft  iron  reaching  posteri- 
orly in  the  middle  line  of  the  leg  from  the  angle  of  the 
scapula  to  the  lower  third  of  the  leg.  It  is 
shaped  to  fit  the  curve  of  the  buttock  by  being 
bent  at  an  angle,  as  shown  in  the  illustration. 
Above  it  terminates  in  a  chest  band,  which 
should  encircle  three-fourths  of  the  chest  and 
be  riveted  at  right  angles  to  the  upright.  There 
is  also  a  semicircular  thigh  band,  which  should 
be  placed  an  inch  or  two  be- 
low the  perineum,  to  encircle 
two-thirds  of  the  thigh  pos- 
teriorly. A  leg  band  should 
terminate  the  splint  at  the 
bottom,  which  should  in  the 
same  way  encircle  two-thirds 
of  the  calf. 

These  bands  should  be 
made  of  hoop  iron,  and 
should  be  so  placed  on  the 
upright    that     two-thirds    of 

the 
well  side  of  the  stem  and 
one-third  to  the  diseased  side. 
The  upright  should  be 
made  of  iron  |  X  tb"  of  an 
inch.  The  chest  band  should 
be  \\  inches  wide,  and  the  other  bands 
f  of  an  inch. 


m 


Fig.     2. —  DIA 

GRAMMATic  OUT-   each  baud  should  be   to 

LINE  OF  SPLINT, 
SHOWING  THE 
PARALLELISM  BE- 
TWEEN THE  BODY 
PORTION  AND  LEG 
P  O  R  T  I  ON  (rid- 
lon). 


Fig.  3. —  SHOWING  THE 
SPLINT  IN  ITS  SIMPLEST 
FORM,  NOT   YET   PADDED  OR 

to  the  bend  for  the  buttock,  as  shown  in  covered  (ridlon). 


Before  the  splint  is  applied,  in  addition 


'H.  O.  Thomas,  Diseases  of  the  Hip,  Knee,  and  Ankle. 


THE    TREATMENT    OF    HIP    DISEASE 


73 


the  diagram,  a  twist  should  be  made  in  the  upright's  longi- 
tudinal axis  between  the  thigh  and  body  bands,  so  that  the 
thigh  and  leg  part  of  the  splint  shall  lie  somewhat  nearer 
the  median  part  of  the  body  than  the  body  part. 

If  flexion  of  the  thigh 
is  present,  the  leg  piece 
is  bent  at  such  an  an- 
gle to  the  body  piece 
that  it  fits  the  angle  of 
flexion. 

The  splint  is  now  ap- 
plied, as  shown  in  the 
figure,  and  secured  to 
the  body  by  means  of 
a  bandage  connecting 
the  ends  of  the  chest 
piece  and  running  over 
the  shoulders.  The  leg 
is  secured  by  leather 
straps  or  by  a  common 
bandage  to  the  leg 
piece  of  the  splint. 

If  it  is  to  be  used  as 
a  walking  splint,  a  pat- 
ten is  put  on  the  well 
leg,  and  the  patient  al- 
lowed to  use  crutches. 
If  muscular  spasm  is 
present  to  any  degree, 
the  patient  is  kept  in  bed  with  the  splint  on  till  it  im- 
proves or  subsides.  If  flexion  is  present,  the  splint  is 
made  a  little  straighter  than  the  angle  of  flexion,  and  the 
deformity  corrected  at  small  stages  by  this  forcible  means. 

There  are  two  points  in  the  use  of  the  splint  upon  which 
Mr.  Thomas  laid  much  stress.  The  patient  must  not  go 
about  while  acute  muscular  spasm  and  joint  irritability  are 
present.     The  limb  must  not  be  disturbed  even  for  purposes 


Fig.  4. 


■THOMAS   SPLINT    APPLIED   WITH    PATTEN  AND 
CRUTCHES    (riDLOn). 


74 


DISEASES    OF    THE    HIP    JOINT 


of  examination  unless  absolutely  necessary,  and  then  only  at 
intervals  of  weeks  or  months.  Consequently,  all  rebending 
of  the  splint  should  be  done  without  removing  it.  By  means 
of  wrenches  this  is  easily  accomplished. 


Advantages  of  the  Splint. 

It  furnishes  fairly  good  fixation  ;  better,  probably,  than  any 

other  apparatus.  It 
is  cheap  and  simple, 
and  can  be  made  by 
any  blacksmith  or  by 
the  surgeon  himself. 
In  general,  English 
experience  in  the  use 
of  the  splint  is  favor- 
able, and  extremely 
good  results  have 
been  reported  by  Mr. 
Marsh. 


Objections  to  the  Splint. 

Theoretically,  the 
worst  objection  to  the 
splint  is  that  there  is 
no  provision  for  mak- 
i  n  g  traction  ;  and 
traction  is  recognized 
by  most  surgeons  who 
are  familiar  with  the 
phenomena  of  hip  dis- 
ease as  an  essential 
in  a  certain  large  pro- 
portion of  cases. 
Again,  from  a  me- 
chanical point  of  view 
there  is  a  serious  practical  objection   to   the  Thomas  splint. 


Fig.  5- — A  CASE  OF  HIP  DISEASE,  WHICH  HAD  BEEN 
UNDER  THE  CARE  OF  MR.  THOMAS,  SHOWING  A  SPLINT 
WHICH  HAD  BEEN  OUTGROWN  AND  NEGLECTED  BY  THE 
PATIENTS,      THE     RESULT     BEING     CONSEQUENTLY     POOR. 

(The  preceding  figure  shows  the  splint  properly  applied.) 


THE    TREATMENT    OF    HIP    DISEASE 


75 


The  leg  is  bandaged  firmly  to  the  splint,  and  is  held  to  it 
much  more  firmly  than  the  body  can  possibly  be  held  by  the 
chest  piece.  Consequently,  in  walking  or  being  moved,  the 
body  piece  moves  on  the 
body  and  twists  and  jars 
the  leg,  causing  irritation 
of  the  joint.  This  is  an 
important  matter  on  ac- 
count of  the  long  leverage 
which  the  body  piece  pos- 
sesses over  the  leg  piece. 

Again,  inasmuch  as 
nothing  is  done  to  coun- 
teract muscular  spasm, 
the  head  of  the  bone  is 
continually  crowded 
against  the  acetabulum's 
upper  rim,  and  both  are 
worn  away,  causing  un- 
necessary shortening. 
And,  if  an  attempt  is  made 
to  remedy  flexion  by  forc- 
ing the  leg  straight,  it  is 
obvious  that  it  must  be 
done  by  using  the  surfaces 
of  the  hip  joint  as  a  ful- 
crum, thereby  increasing 
the  interarticular  pressure, 
and    with    it    the    osseous 

destruction.  This  objection  has  been  urged  against  the 
splint  by  American  writers,  and  was  resented  by  Mr. 
Thomas. 

In  general,  American  experience  has  not  been  favorable 
with  the  use  of  this  splint.  A  series  of  cases  in  which  it 
was  used  were  reported  in  the  Transactions  of  the  American 
Orthopedic  Association,  Vol.  II.     In  nearly  every  case  of  the 


Fig.  b. —  THE     SAME     CASE     AS     FIG.     5,    SHOWING 
ABSCESSES    AND    MALPOSITION   OK    THE    LIMB. 


76 


DISEASK    OF    THE    HIP    JOINT 


twenty-one  the  splint  proved  unsatisfactory.  The  writer's 
personal  experience  with  the  splint  has  shown  that  it  is  hard 
to  adjust,  difficult  to  keep  in  place,  that  in  his  hands  it  does 
not  allav  pain  in  any  degree  as  traction  does,  and  that  it 
does  not  counteract  muscular  spasm,  in  consequence  of  which, 

elevation  of  the  trochanter  and 
much  shortening  ensue.  In  cer- 
tain mild  cases,  where  there  is 
little  pain  or  tendency  to  deform- 
ity, it  answers  admirably  ;  but  in 
cases  of  average  severity  it  does 
not  vield  as  good  results  as  other 
methods. 

Phelps  s  Fixation  Appliance. 

Dr.  Phelps  *  has  described  a 
fixation  appliance  made  of  a  wood- 
en frame  re-enforced  by  plaster  of 
Paris,  which  should  furnish  com- 
plete fixation;  but  such  elaborate 
appliances  seem  cumbersome, 
when  compared  with  the  simple 
bed-frame  to  be  described  later, 
which  furnishes  practically  com- 
plete fixation 

Other  methods  of  fixation  are 
found  in  the  use  of  plaster  of 
Paris,  leather,  and  metal  splints. 

The  plaster  of  Paris  spica  splint 

is  easily  applied.     It  affords  good 

fixation  and  is  inexpensive.     The 

leg  and  thorax  should  be  wrapped 

in    sheet    wadding,  and  rollers  of    washed    crinoline    gauze 

impregnated  with  plaster  should   be  applied.     The   bandage 

should  reach  from  the  lower  part  of  the  thorax  to  the  lower 


Fig.  7.— MARKED  ATROPHY  AND 
SHORTENING  OCCURRING  IN  THE  USE 
OF  THE  THOMAS  SPLINT  IN  AN  AV- 
ERAGE  CASE   OF   HIP   DISEASE. 


■X.Y.  Med.  Rec.  March  4-  1SS9. 


THE    TREATMENT    OF    HIP    DISEASE 


77 


third  of  the  calf.  It  is  not  possible  to  obtain  firm  fixation 
without  encircling  the  thorax  ;  and,  if  absolute  fixation  is  re- 
quired, the  spica  should  include  the  well  leg  also.  It  is  wise 
to  incorporate  a  strip  of  iron  in  the  front  of  the  bandage,  as 
the  splint  tends  to  crack  in  the  groin  unless  made  very 
strong;  there. 


Fig.    8. —  PHEI.PS'S    FIXATION   SPLINT   (pHELPs). 


The  objections  to  the  plaster  splint  are  that  it  becomes 
loose  very  easily,  allowing  motion  at  the  hip  and  chafing  over 
the  bony  prominences,  and  that  it  is  at  best  a  dirty  dressing, 


y8  DISEASES    OF    THE    HIP    JOINT 

as  it  is  not  possible  to  keep  it  from  getting  urine-soaked;  and 
in  dirty  children  it  becomes  extremely  filthy  in  a  very  short 
time,  so  that  frequent  reapplication  becomes  necessary. 

Its  best  use  is  found  in  patients  who  cannot   afford   any 
appliance  or  who  are  hopelessly  careless  and  ignorant.     It 


Fig.    9. —  THE   PLASTER   OF   PARIS    BANDAGE. 

is  also  of  much  use  in  cases  where  malposition  of  the  hip  has 
been  corrected  under  ether,  and  where  it  is  desired  to  keep 
the  hip  from  returning  to  the  position  of  deformity. 

Moulded  leather  splints  are  cleaner,  and  are  much  used  in 
the  West.     They  are  made  of  stout  sole  leather,  and  are  re- 


THE    TREATMENT    OF    HIP    DISEASE 


79 


inforced  by  steel  strips,  lacing  in  front.     It  is  obvious  that 
they   cannot    afford    as    complete    fixation    as  the    methods 
just  mentioned.     Those  who  use  the  splints,  however,  obtain 
very    good    results ;     and    the 
writer,    being    perhaps    preju- 
diced in  favor  of  traction  meth- 
ods, has  not  had  any  personal 
experience  in   their  use. 

Fixa  t  i  o  n 
splints  may 
also  be  made 
of  silicate, 
metal,  copper 
gauze,  or  any 
similar  mate- 
rial. They 
are  made  of 
the  same  pat- 
tern as  those 
described  and 
are  open  to 
the  same  criticisms. 

The  Gouttiere  de  Bonnet  is  a  wire  frame 
to  hold  the  body  and  legs.  It  was  for- 
merly used  after  excisions,  and  is  now  but 
little  known.  It  of  course  furnishes  com- 
plete fixation. 

The    Cabot    splint   discussed    at    length 
under  acute  arthritis  *  affords  fair  fixation 
of    the   hip,  and  is  useful    in   the   case    of 
young    children,    especially    where   flexion 
*^     deformity  is  present. 

Fig.   II. —  GOUTTIERE    DE 


Fig.  lo. — Vance's  moulded  leather 

SPLINT. 


'  See  Fig.  i,  p.  25 


8o  DISEASES    OF    THE    HIP    JOINT 

Objections  to  Trealment  by  Fixation. 

It  is  not  to  be  feared  that  fixation  of  a  diseased  joint  will 
lead  to  anchylosis  if  carried  on  through  the  acute  inflamma- 
tion. Rather  it  is  to  be  regarded  as  a  means  of  preserving 
mobility,  by  limiting  so  far  as  may  be  the  inflammatory  or 
destructive  process.  This  matter  has  been  discussed  by 
Verneuil  at  the  Society  of  Surgery  in  Paris  in  1879,  and 
more  recently  some  admirable  experimental  work  has  been 
done  by  Dr.  Phelps,*  showing  that  fixation  per  se  does  not 
produce  anchylosis.  Fixation  cannot,  therefore,  be  con- 
sidered objectionable  on    that  ground. 

The  absence  of  traction  is,  to  the  writer's  mind,  the  cardi- 
nal objection  to  fixation  methods.  The  reasons  why  traction 
seems  of  such  importance  will  be  considered  in  the  next  sec- 
tion. Practically,  fixation  is  at  fault  in  not  being  complete ; 
for,  short  of  immobilization  of  the  whole  body,  it  is  almost 
impracticable  to  obtain  real  fixation  of  the  hip  joint. 

At  the  same  time  it  must  be  remembered  that  it  is  in  a 
degree  a  question  of  personal  opinion  and  of  geographical 
location, —  that  English  surgeons  claim  excellent  results, 
and  that  French  surgeons  incline  much  to  the  fixation 
method  ;  but,  on  the  other  hand,  in  America,  where  modern 
orthopedic  surgery  had  its  birth,  and  has  reached  its  highest 
development,  methods  of  treatment  by  fixation  alone  are 
almost  wholly  discountenanced  by  the  leading  orthopedic 
surgeons. 

I.     Mechanical  Treatment. 

if)  By  Traction. 

The  treatment  of  hip  disease  by  traction  has  been  prac- 
tised certainly  from  the  early  part  of  this  century.  As  early 
as  1835  Le  Sauvage  t  was  using  it;  and  Dessault  J  was 
using  extension  with  counter-extension   in  the  perineum,  in 

*  N.Y.  Med.  Journal,  May  xt,  iSgo.  t  Arch.   Gen.,  November,  18.^5,  p.  280. 

%  Treatise  on  Tract.,  Philadelphia,  p.  243. 


THE    TREATMENT    OF    HIP    DISEASE  01 

the  last  century,  for  thigh  fractures.  The  use  of  traction  in 
hip  disease  while  the  patient  was  going  about  was  intro- 
duced by  Dr.  Henry  G.  Davis  in  1855.  It  was  the  idea  of  Dr, 
Davis  *  that  traction  separated  the  head  of  the  femur  from 
the  acetabulum  and  permitted  "motion  without  friction." 

With  some  slight  modifications  the  splint  of  Davis  is  the 
one  in  use  to-day  under  the  names  of  the  Davis,  Taylor,  or 
Sayre  splint.  It  is  more  correctly  called  at  times  the  long 
traction  splint. 

It  would  seem  useless  to  enter  upon  the  discussion  rela- 
tive to  the  original  ideas  of  Davis  as  modified  by  his  fol- 
lowers. The  subject  has  been  discussed  at  much  length  by 
Thomas,!  Ridlon,|  Shaffer,§  and  Judson,||  and  references 
are  given  to  the  controversial  articles.  It  seems  better  to 
pass  at  once  to  modern  ideas  regarding  traction  and  its 
application  to  the  treatment  of  hip  disease. 


The  Theory  of  the  Use  of  Traction  in  Hip  Disease. 

The  evil  effects  of  the  muscular  spasm  in  causing  bone 
destruction  and  shortening  have  been  several  times  alluded 
to.  Any  measure  which  will  tend  to  diminish  this  feature 
of  the  disease  will  be  rational. 

Moreover,  traction  is  exerted  instinctively  by  children 
with  hip  disease,  when  one  leg  is  pulled  down  by  the  other, 
as  shown  in  the  picture, —  an  attitude  very  common  in  acute 
hip  disease.  Thus,  by  theory  and  by  an  indication  from 
nature,  traction  would  seem  to  be  of  use.  Practically,  it 
is  a  matter  of  general  information  that  traction  is  a  sedative 
to  muscular  irritability  (as  in  fractures  of  the  thigh),  and 
that  in  hip  disease  it  quiets  pain  more  quickly  than  any 
other  measure  when  applied  simply  by  the  surgeon's  hand. 

*  American  Medical  Momhly,  1859,  p.  361. 

t  An  Argument  with  the  Censor  at  St.  Luke's  Hospital,  New  York.    London,  iS8g. 

X  Medical  Record,  Sept.  15,  1888.  §  Trans.  Am.  Orth.  Ass'n,  vol.  ii. 

II  N.Y.  Medical  Record,  July  7,  1883  ;  Lancet,  Dec.  2,  1888. 


82 


DISEASES    OF    THE    HIP    JOIXT 


It  has  been  a  matter  of  much  discussion  whether  or  not 
traction  separates  the  articular  surfaces  at  the  hip. 

If  traction  is  made  upon  a  healthy  adult  joint,  the  head  of 
the  femur  impinges  upon  the  lower  edge  of  the  acetabulum, 

and  a  straight  downward  pull  is  hardly  sufficient  to  separate 
it  from  the  socket;  but  abduction  of  the  limb,  while  traction 
is  being  made,  renders  distraction  of  the  joint  surfaces  pos- 
sible. In  children  the  cotyloid  ligament  is  less  developed, 
and  distraction  can  be  obtained  in  the  cadaver  by  a  down- 
ward pull,  on  account  of  the  shallow  acetabulum.  In  a 
diseased  hip  joint,  where  the  tissues  are  softened  and  in 
part  disintegrated,  distraction  would  seem  to  be  more  easily 
obtainable. 


INSTINXTIVE    EFFORT    AT    TRACTION. 


Experiments  upon  the  cadaver  and  under  ether  are  not 
conclusive,  because  they  do  not  reproduce  the  most  im- 
portant condition  of  all, —  the  muscular  spasm.  Konig  made 
frozen  sections  of  hips,  both  with  and  without  traction,  and 
concluded  that  traction  of  8  pounds  caused  separation  of 
.5  to  2.-5  millimetres.  These  results  were  confirmed  by 
Paschen,  but  ?vIoroso£f*  reached  diametrically  opposed  con- 
clusions. Unlike  Konig,  he  found  that,  under  normal  con- 
ditions, the  two  joint  surfaces  were  in  intimate  contact,  and 
that  it  required  40  to  60  pounds  of  traction  to  cause  dias- 
tasis.    Lannelongue,  however,  found  results  in  accord  with 

*  Quoted  by  Lannelongue,  Coxotuberculose.     Paris,  i8S6. 


THE    TREATMENT    OF    HIP    DISEASE  Sj 

those  of  Konig.  He  used  for  the  experiment  the  cadaver 
of  a  boy  four  years  old  afflicted  with  hip  disease  for  five 
months.  After  death  from  croup,  a  weight  of  4  kilogrammes 
was  applied,  as  it  had  been  in  life,  and  the  body  was  frozen. 
Section  of  the  diseased  hip  showed  a  separation  of  2  milli- 
metres between  the  diseased  joint  surfaces. 

The  most  careful  and  most  practical  experiments  in  this 
very  important  matter  have  been  made  and  recorded  by  Dr. 
E.  G.  Brackett.*  In  a  series  of  experiments  upon  the 
cadaver,  steel  pins  were  driven  into  the  os  pubis,  trochanter, 
and  femur  of  6  adult  subjects,  and  4  showed  evidence  of 
joint  separation  of  from  2  to  8  millimetres,  when  traction  of 
25  pounds  was  used.  One  of  the  failures  was  caused  by  a 
rheumatic  change  in  the  joint,  and  in  the  other  case  stiff- 
ness of  the  joint  was  present.  In  the  cadaver  of  a  girl  three 
years  old  a  traction  hip  splint  was  applied,  and  a  separation 
of  the  joint  surfaces  of  from  2  to  6  millimetres  was  obtained. 

It  was  found  that,  owing  to  the  obliquity  of  the  acetabulum, 
the  first  change  to  occur  when  diastasis  is  being  produced  is 
an  outward  displacement  of  the  trochanter,  caused  by  the 
slipping  of  the  head  of  the  femur  on  the  oblique  surface  of 
the  acetabulum.  Consequently,  any  separation  of  the  joint 
surfaces  will  show  first  as  an  increase  in  the  distance  be- 
tween the  trochanters.  This  can  be  measured  in  the  living 
subject,  and  showed  in  a  series  of  experiments  on  living 
children  with  hip  disease  that  distraction  of  the  joint  was 
produced  by  mild  traction  to  the  degree  of  2  to  2.5  milli- 
metres. In  two  cases,  it  was  possible  to  measure  the  increase 
in  length  directly,  as  the  bony  landmarks  were  peculiarly 
definite  and  showed  a  separation  of  3  and  8  millimetres  be- 
tween the  joint  surfaces.  These  experiments  of  Brackett 
serve,  therefore,  in  connection  with  the  others,!  to  establish 
the  probability  that  traction  produces  very  decided  modifica- 
tion  of  intra-articular  pressure,  and  in  some  instances  un- 

*  Trans.  Am.  Orth.  Ass'n,  vol.  ii.  p.  207. 

t  Bull,  et  Mem.  de  la  Soc.  de  Chir,  1886,  xii.  31 ;  Deutsch.  Z.  f.  Chir.,  1S73,  iii.  256;  Boston 
M.  and  S.  Journal,  1880,  ciii.  465,  and  Aug.  30,  1888;  Trans.  Am.  Orth.  Ass'n,  vol.  i.  ]>.  193. 


84  DISEASES    OF    THE    HIP    JOINT 

doLibtedly  results  in  distraction  of  the  joint  surfaces.  This 
furnishes  a  rational  and  scientific  explanation  for  the  use  of 
traction. 

It  is  not  likely,  however,  that  traction  necessarily  pro- 
duces separation  of  the  joint  surfaces  before  it  affords  relief. 
On  the  other  hand,  even  mild  traction  made  with  the  hand 
is  very  often  enough  to  control  muscular  irritability  and 
relieve  much  discomfort.  In  these  cases,  it  seems  to  act  as 
a  sedative  to  the  muscles,  probably  by  slightly  stretching 
them,  and  to  have  its  beneficial  effect  on  that  account 
rather  than  because  any  notable  joint  separation  has  oc- 
curred. 

Traction  is  used  in  two  ways  in  hip  disease, —  during  re- 
cumbency and  by  means  of  portative  appliances. 

Traction  during  Recumbency. 

This  older  method  of  treatment  is  exerted  by  means  of 
the  weight  and  pulley,  and,  to  be  of  use,  must  be  rationally 
applied.  It  is  of  use  where  malposition  of  the  limb  or  a 
sensitive  condition  of  the  joint  is  present,  and  in  cases  where 
apparatus  is  not  to  be  obtained.  On  general  principles  pro- 
longed recumbency  is  to  be  avoided  during  hip  disease. 
Exercise  within  certain  restricted  limits  and  fresh  air  are  all 
therapeutic  measures  which  are  of  the  greatest  value  in  con- 
trolling the  disease  and  keeping  the  general  condition  as 
good  as  possible.  During  certain  complications  recumbency 
is  indicated  ;  but,  as  a  rule,  it  should  only  be  resorted  to  when 
ambulatory  treatment  proves  impracticable. 

It  should  be  added  that  this  is  not  in  accord  with  the 
ideas  of  many  eminent  English  surgeons,  notably  Mr.  How- 
ard Marsh. 

During  recumbency  the  patient's  body  should  be  secured 
and  kept  quiet.  Without  this,  one  loses  half  of  the  efficiency 
of  the  method.  The  best  means  of  securing  the  patient  is 
by    means   of  a   light    bed-frame,    to    which    the    patient   is 


THE    TREATMENT    OF    HIP    DISEASE 


85 


Strapped.  An  oblong  frame,  a  little  wider  and  a  little  longer 
than  the  patient,  is  made  of  ^-inch  gas-pipe,  being  joined  at 
the  four  corners  by  common  gas-pipe   "shoulders."     It  can 


^ 

w 

.... 

n 

tic 

Jll/I  \\'.tt\ 



n9 

Fig.   13. —  BRADFORD    BED-FRAME. 


be  covered  with  stout  cloth, 
which  should  be  tightly 
stretched  over  the  bars, 
and  over  the  buttocks  it 
should  be  omitted,  to  al- 
low for  the  use  of  the  bed- 
pan. 

The  patient  is  secured 
to  this  by  straps  passing 
over  the  chest  and  by  a 
band  around  the  pelvis. 
This  makes  it  impossible 
for  the  patient  to  sit  up 
or  roll  over,  which  he  is 
sure  to  do  if  left  free  in 
bed  ;  and  it  insures  quiet 
to  the  joint. 

Traction  is  applied  by 
means  of  a  weight  pull- 
ing upon  adhesive  plaster 
attached  to  the  leg.  Two 
strips  of  surgical  adhesive 
plaster  are  sewed  to  web- 
bing, which  should  project 
below    the    foot.       These 

plaster  strips  run  upward  from  the  malleoli  inside  and  out- 
side of  the  leg  and  thigh ;  and  they  are  further  secured  in 


Fig.  14. —  A    PLASTER    HIP    EXTENSION    APPLIED. 


86 


DISEASE    OF    THE    HIP    JOINT 


place  by  a  basket-work  made  by  two  other  strips  of  plas- 
ter running  around  the  leg  and  thigh.  This  gives  a  firm 
hold  upon  the  skin  of  the  leg  to  the  webbing  which  pro- 
jects below  the  foot.  This  is  buckled  to  a  crosspiece  of 
wood  from  which  runs  a  cord  over  a  pulley  at  the  bottom 


Fig.    15. —  WEIGHT    AXD    PULLEY    APPARATUS    FOR    BED    TRACTION'. 

of  the  bed.  To  this  cord  a  weight  of  from  3  to  5  pounds 
is  attached.  In  acutely  painful  cases  a  heavier  weight 
may  be  temporarily  required. 

The  foot   of  the  bed  should  be    elevated    to    provide  for 


THE    TREATMENT    OF    HIP    DISEASE  8/ 

counter-traction,  else  the  child  will  be  continually  pulled 
down  by  the  weight. 

Tractioji  should  always  be  made  in  the  line  taken  by  the  leg 
when  the  pelvis  is  made  square,  otherwise  it  is  likely  to  prove 
painful.  Traction  thus  made  is  a  sedative  measure,  and 
tends  to  quiet  muscular  irritability  and  to  reduce  deformity. 

The  use  of  a  long  outside  splint  or  any  other  appliance, 
except  in  cases  of  deformity  (when  it  may  be  necessary  to 
elevate  the  leg  on  an  inclined  plane),  is  wholly  unnecessary. 

Traction  may,  however,  be  made  in  bed,  when  deformity 
is  present,  without  the  use  of  the  weight  and  pulley,  by 
applying  a  long  traction  splint  to  the  limb,  and  then  placing 
the  limb  in  the  deformed  position. 

Traction  in  bed  is  only  indicated  in  acutely  painful  cases, 
in  cases  where  deformity  is  present,  and  where  apparatus  is 
not  to  be  obtained. 


Traction  by  Means  of  Splints. 

Any  traction  splint  consists  of  an  upright  furnished  below 
with  some  appliance  to  pull  down  upon  the  leg  straps,  while 
above  it  terminates  in  an  arm  or  band  to  take  a  hold  upon 
the  pelvis  and  furnish  a  point  of  counter-extension  by  means 
of  straps  passing  under  the  perineum. 

The  conventional  long  traction  splint  consists  of  a  steel 
pelvic  band,  made  either  straight,  or  curved  in  the  manner 
shown  which  enables  it  to  fit  more  closely  to  the  crest  of 
the  ilium  and  take  a  firmer  hold  on  the  pelvis.  This  arm 
may  be  long  or  short,  curved  or  straight. 

The  pelvic  band  should  be  riveted  to  the  upright  at  an 
angle  with  the  anterior  arm  lower.  The  upright  should 
reach  from  the  pelvic  band  (which  should  be  at  a  level 
with  the  anterior  superior  iliac  spines)  to  two  inches  below 
the  sole  of  the  foot,  and  should  be  curved  out  a  little  at  the 
top  to  avoid  the  fulness  of  the  thigh.  This,  however,  is  not 
essential.     Below,  it  should    terminate    in    an    arm    with    a 


DISEASES    OF    THE    HIP    JOINT 


windlass  provided  with  pins,  upon  which  the  extension  straps 
can  be  wound  up.      This  is  the  cheapest  form  of  apparatus. 


Fia;.  i6. 


Fig.  17. 


Fig.   16. —  SPLINT   WITH    CUR\"ED    BAND.      FigS.    17    and    iS. —  SPLINT   WITH    STRAIGHT    BAND    FOR 

LEFT    LEG. 

A  more  expensive  and  more  convenient  one  can  be  made 
by  having  the  lower  part  of  the  splint  slip  inside  of  the 
upper  part,  at  a  point  one-third  of  the  way  up  the  leg,  where 
the  inner  piece  is  controlled  by  a  ratchet  cut  into  it,  and  the 
whole  upright  can  be  lengthened  or  shortened  by  means  of  a 
cogged  key.  In  this  way  no  windlass  is  needed  on  the  foot 
piece,  which  requires  only  buckles  ;  and  the  traction  is  ob- 
tained by  lengthening  the  upright  by  means  of  the  ratchet 
and  key. 


THE    TREATMENT    OF    HIP    DISEASE 


89 


Fig.  2o.- 


■RATCHET    AND 
SIGN. 


CE^•     rXTEN- 


Fig.   19  — WINDLASS    AND   EXTENSION    AS    USED    IN 
THE    LONG   TRACTION    SPLINT. 

The  splint  is  provided  with  an 
anterior  pad  over  the  thigh  and  a 
posterior  arm  behind  the  calf. 

If  the  windlass  pattern  is  used, 
some  provision    should  be  made 

for  increasing  the  length  of  the  splint  as  the  child  grows. 
This  is  done  by  having  the  two  pieces  overlap  and  screwed 
together.  The  pelvic  band  should  buckle  around  the  waist 
and  be  padded  with  leather,  as  should  also  be  done  to  the 
plate  and  arm.  The  splint  should  be  made  as  light  as  is 
consistent  with  strength. 

Perineal  bands  are  attached  to  the  pelvic  band,  so  as  to 
pass  under  the  tuberosity  of  the  ischium  as  nearly  as  may  be. 
They  can  be  made  of  webbing,  covered  with  Canton  flannel, 
or  of  leather  moulded  over  a  leather  strap. 

The  care  of  the  perineum  is  an  important  matter  in  hip 
disease,  and  it  should  be  hardened  by  alcohol  and  kept  dry 
by  some  dusting  powder.     If  sloughs  form,  the  splint  should 


90 


DISEASE    OF    THE    HIP    JOINT 


be  removed,  and  they  should  be  dressed  with  some  simple 
ointment. 

Traction  splints  may  be  made  with  one  anterior  and  one 
posterior  horn  instead  of  a  band,  and  be  provided  with  only 
one  perineal  band.  These  furnish  much  less  fixation  than 
the  others,  and  are  not  suited  to  severe  cases,  especially  in 
hospital  practice. 


''    Fig.    22. —  CURVED    TWO-BAND   HIP 

SPLINT  APPLIED  (which  follows  more 
closely  the  outline  of  the  crest  of  the 

ilium). 


Fig.  21. —  STRAIGHT    TWO-BAND    HIP    SPLINT    APPLIED. 


If  there  is  a  sinus  over  the  trochanter  or  tenderness  there, 
it  is  often  a  matter  of  much  convenience  to  split  the  upright 


THE    TREATMENT    OF    HIP    DISEASE 


91 


over 
cases, 


the 
the 


outer 
splint 


surface  of  the  thigh,  as  shown.  In  other 
may  be  applied  over  the  dressing. 
A  cheap  hip  splint, 
made  of  gas-pipe,  has 
been  described  by 
the  writer,*  where 
traction  i  s  t  o  be 
made  by  means  of 
leather  straps  a  t- 
tached  to  the  foot 
piece  instead  of  by 
a  windlass.  The 
splint  should  cost 
only  one  or  two  dol- 
lars, and  is  fairly 
efficient. 

Judson's  splint,  or 
ischiatic  crutch,  dif- 
fers somewhat  from 
the  others.  It  is  in- 
tended to  exert  only 

T-i-  T      1    4.        i  i.-  J  Fig.    24. —  DIAGRAM    OF   CHEAP 

Fig.  23.- SPLINT  WITH     slig-ht    traction,  and        ^ 

OPEN       SPACE       OVER     THE  ,='  ,.  .  '  ,  GAS-PIPE   HIP   SPLINT. 

TROCHANTER.  thc    spliut   IS    madc 

heavier  above  than  below,  so  that  the 
centre  of  gravity  is  higher  and  makes  walking  with  it  easier. 
The  pelvic  band  is  covered  with  hard  rubber,  which  is  a 
cleanly  but  expensive  method.  The  splint,  in  a  modified 
form,  can  be  made  very  cheaply,  however,  and  is  much  used 
in  New  York  clinics.  It  is  open  to  the  same  objection  as 
are  all  traction  splints  not  supplied  with  some  better  ap- 
pliance than  straps  for  obtaining  traction.  It  does  not  pull 
evenly  or  strongly  enough. 

Such  a  splint  as  one  of  these  should  be  worn  through  the 
acute  stage  of  the  disease,  until  muscular  spasm  on  manipu- 
lation has  been  absent  for  some  months,  as  well  as  pain. 


R.  W.  Lovett,  Boston  Med.  and  Surg.  Journal,  March  12,  1S91. 


92 


DISEASES    OF    THE    HIP    JOINT 


It  is  safer  to  begin  with  the  use  of  crutches,  and  building 
up  the  well  foot  by  so  high  a  patten  that  the  splint  swings 
clear  of  the  ground  in  walking.  Later  the  bottom  of  the 
splint  may  be  shod  with  leather,  and  the  patient  allowed  to 
walk  directly  on  it.  In  children  under  careful  control,  and 
in  the  mildest  cases,  this  may  be  done  at  first,  but  it  adds  to 
the  risk. 

The  splint  serves  as  a  protection  splint  as 
well  as  a  traction  appliance,  inasmuch  as  it  re- 
moves the  body  weight  from  the  leg,  even 
where  the  patient  walks  upon  the  splint.  Its 
attributes  as  a  fixation  appliance  will  be  dis- 
cussed in  a  subsequent  section. 

The  material  of  which  the  splint  is  made 
is  a  matter  of  detail,  and  the  same  may  be 
said  of  the  pattern  used.  The  essential  mat- 
ter is  to  have  an  appliance  which  holds  the 
pelvis  as  a  basis  for  counter-extension,  and 
which  projects  below  the  foot  enough  to  pull 
the  leg  down.  When  this  is  once  understood, 
the  construction  of  an  appliance  is  compara- 
tively an  easy  matter. 

These  splints  should  be  worn  night  and  day, 
and  the  limb  disturbed  as  little  as  possible 
when  they  have  to  be  removed.  When  the 
splint  is  not  in  place  and  exerting  traction, 
25.— juD-  the  leg  should  be  gently  pulled  down  by  the 
hand  until  the  traction  straps  are  fastened  in 
place. 
In  all  probability  the  splint  will  have  to  be  worn  from  two 
to  five  years.  Most  cases  under  control  recover  from  their 
acute  symptoms  in  two  or  three  years  ;  but  a  longer  course 
of  disease  is  common,  and  is  not  inconsistent  with  a  favor- 
able issue. 


SON  S    PERINEAL 
CRUTCH 


THE    TREATMENT    OF    HIP    DISEASE 


93 


Faulty  Appliances. 

Traction  splints  which  are  jointed  at  the  junction  of  the 
upright  and  pelvic  band,  although,  perhaps,  in  accord  with  the 
ideas  of  the  originator  of  the  splint,  are  not  regarded  to-day 
as  desirable.  The  problem  is  not  to  facilitate,  but  to  re- 
strict, motion  at  the  hip  lip. 

Sayre's  short  splint  is  almost  worthless.  It  is  too  short 
to  obtain  any  pull  upon  the  hip  worth  mentioning,  and  it 
does  not  grasp  the  pelvis.  It  is 
but  little  used,  although  sold  by 
the  instrument-makers.  Elastic 
perineal  straps  are  faulty,  and 
cause  constant  relaxation  of  trac- 
tion and  jarring  to  the  hip.  They 
are  almost  never  seen  outside  of 
the  instrument-makers'  shops. 

The  Practical  Objections  to  Traction. 

Theoretically,  traction  as  a  treat- 
ment of  hip  disease  rests  upon  a 
scientific  basis.  Practically,  it  has 
some  disadvantages. 

The  skin  is  frequently  made  sore 
by  the  constant  irritation  from  the 
plaster,  and  frequent  changes  of 
plaster  are  necessary.  If  the  plas- 
ter is  applied  below  the  knee,  and 
does  not  have  a  hold  upon  the 
thigh,  the  knee  ligaments  will  be 
weakened  and  the  knee  hyper-ex- 
tended. 

In  some  rare  instances,  traction 
causes  pain,  as  in  two  cases  recently  reported  by  Ridlon  ; 
but   such  cases  are  so  rare  that  they  may   be  left   out   of 
account. 


Fig.  26.- 


■SAYRE  S    SHORT    SPLINT. 


94  DISEASES    OF    THE    HIP    JOINT 

A  serious  objection  to  the  long  traction  splint,  and  one 
which,  in  the  writer's  mind,  makes  the  routine  use  of  crutches 
almost  advisable,  is  that,  when  the  patient  steps  upon  the 
splint,  the  traction  is  lessened ;  and  often  the  traction  straps 
can  be  seen  to  hang  loosely  as  the  body  sags  down  in  the 
perineal  bands.  This  leads  to  a  series  of  jerks  to  the 
diseased  joint.  Attempts  have  been  made  to  remedy  this 
by  the  insertion  of  a  spring  in  the  shaft  of  the  splint ;  but 
such  an  arrangement  is  expensive  and  complicated. 

The  use  of  elastic  traction  straps  is  not  to  be  advocated* 
because  elastic  appliances  are  always  uncertain  quantities, 
and  generally  exert  too  much  or  too  little  traction  at  any 
given  time.  The  problem  is  very  easily  solved  by  the  use 
of  crutches. 

The  Theoretical  Objections  to  Traction. 

In  addition  to  the  practical  objections  to  the  treatment  of 
hip  disease  by  traction,  there  are,  in  the  writer's  opinion, 
certain  theoretical  objections  also,  which  demand  considera- 
tion and  discussion.  The  most  important  question  in  this 
regard  is  the  consideration  of  the  fixative  power  of  traction. 
Does  traction  immobilize  a  diseased  joint,  or,  if  not,  does  it 
furnish  practical  fixation  enough  to  protect  it  from  traumat- 
ism .-•  This  question  is  one  which  is  not  only  theoretical, 
but  practical,  and  affects  very  strongly  the  whole  question 
of  the  ambulatory  treatment  of  hip  disease.  The  American 
traction  splint  was  not  introduced  with  the  idea  that  it  was 
a  fixative  appliance.  Dr.  Henry  G.  Davis  believed  that  it 
allowed  "  motion  without  friction  "  ;  and  Dr.  C.  F.  Taylor, 
in  speaking  of  the  appliance,  spoke  of  it  as  an  apparatus 
which,  first,  should  relieve  pressure  from  the  joint  due  to 
the  muscular  contraction  by  temporarily  destroying  the  mus- 
cular irritability  and  contractibility,  and,  secondly,  should  pro- 
tect the  joint  from  weight  and  concussion.  He  made  no 
mention  of  the  splint  as  a  fixative  appliance,  and  evidently 
did  not  consider  it  as  such. 


THE    TREATMENT    OF    HIP    DISEASE  95 

Later,  however,  traction  seems  to  have  come  to  be  re- 
garded as  a  means  of  fixation,  notably  by  Dr.  A.  B.  Judson, 
v^rho  has  v^ritten  an  article  dealing  with  the  question  of  the 
fixative  power  of  traction  (Medical  Record,  July  7,  1883, 
May  13,  1883).  Dr.  Judson  quotes  Bauer,  Yale,  Wyeth, 
and  Shaffer  as  the  authorities  believing  that  fixation  fur- 
nishes traction. 

Dr.  Judson  believes  "that,  when  the  hip  splint  is  applied 
to  a  patient,  traction  is  made  in  such  a  manner  that  fixation 
is  rendered  more  complete  by  the  part  of  the  apparatus 
which  acts  as  a  brake.  As  applied  to  the  patient,  the  hip 
splint,  when  traction  is  exerted,  makes  friction  on  the  tuber- 
osities of  the  ischia  and  rami  of  the  ischia  and  pubes,  these 
parts  representing  the  periphery  of  a  wheel  revolving  at  the 
upper  end  of  the  femur,  through  a  considerable  arc  in  the 
plane  of  flexion  and  extension.  In  practice  it  is  found  that, 
when  traction  is  made  in  the  case  of  a  patient  to  whom 
the  hip  splint  is  applied,  motion  in  flexion  and  extension 
is  prevented,  although  it  may  not  as  yet  have  been  arrested 
by  the  disease." 

These  theoretical  considerations,  however,  have  not  stood 
the  test  of  actual  experiments,  as  made  by  the  writer,  who 
reported  to  the  American  Orthopedic  Association  in  1888 
some  experiments  which  seem  to  show  that  in  practice  the 
traction  splint  does  not  furnish  any  considerable  degree  of 
fixation  to  the  hip  joint  (N.Y.  Medical  Journal,  Feb.  8,, 
1889).  A  long  traction  splint  was  fitted  with  a  registering 
appliance  to  record  motion  at  the  hip  joint.  The  shaft  of 
the  splint  was  simply  carried  up  until  it  was  opposite  the 
skin  over  the  crest  of  the  ilium.  This  upper  extremity  of 
the  shaft  was  provided  with  a  pencil  perpendicular  to  the 
skin,  which  recorded  on  the  skin  motion  occurring  at  the 
hip  joint,  if  any  such  took  place. 

The  splint  was  applied  to  a  boy  with  anchylosis  at  the 
hip  joint;  and,  after  walking  with  the  splint,  no  motion  was 
recorded  on  the  skin  over  the  ilium. 


96  DISEASES    OF    THE    HIP    JOINT 

The  splint  was  next  applied  to  a  boy  with  normal  hip 
joints;  and  a  moderate  degree  of  traction  was  applied, 
some  three  and  one-half  pounds  as  registered  by  a  spring 
balance  inserted  in  the  extension  straps.  In  walking  and  in 
sitting,  the  bov's  hip  described  an  arc  of  35  degrees  of  joint 
motion,  as  recorded  by  the  register  of  the  apparatus.  When 
traction  was  increased  so  much  that  it  was  almost  unendur- 
able, the  hip  described  an  arc  of  15  degrees  of  motion;  and 
in  a  second  experiment,  made  with  a  boy  with  healthy  hip 
joints,  the  hip  described  an  arc  of  40  degrees  of  joint  motion 
with  moderate  traction. 

If  these  experiments  show  anything,  it  is  that  "  one  may 
conclude  from  this  that  a  long  traction  splint  with  one 
perineal  band  furnishes  ver}-  incomplete  fixation  to  a  healthy 
hip  joint  with  any  comfortable  degree  of  traction,  and  conse- 
quently to  a  diseased  hip  joint  it  must  furnish  equally  poor 
fixation."  There  is  no  doubt  that,  within  the  limits  set  by 
nature,  motion  in  hip  disease  is  not  harmful.  But  it  must 
be  evident  that  from  a  mechanical  standpoint  it  is  very  diffi- 
cult to  restrain  motion  by  an  apparatus  which  allows  35  or 
40  degrees  of  motion  in  flexion.  If  the  joint  is  one  which 
does  allow  so  large  an  arc  of  motion,  the  long  traction  splint 
is  a  perfectly  efficient  apparatus  under  these  circumstances. 

If,  however,  the  joint  motion  is  limited  by  nature  to  an 
arc  of  15  or  20  degrees,  it  must  be  obvious  that  with  rough 
usage  the  long  traction  splint  must  become  an  inefficient 
appliance,  and  must  allow  motion  beyond  the  proper  limits. 
This,  then,  seems  to  the  writer  a  theoretical  objection  to 
traction  :  that  traction  is  not  fixatioji,  and  does  not  of  itself 
produce  fixation,  and  that  in  practice  the  traction  splints  in 
common  use  are  not  fixation  appliances,  and  are  liable  to 
allow  motion  beyond  the  proper  limits. 

In  view  of  this  the  question  arises.  Is  the  matter  one  of 
any  importance  practically  .'  and  is  not  the  fixation  furnished 
bv  the  traction  splint  sufficient  for  all  practical  purposes  ? 
The  answer  to  this  is  found   in  the  fact  which  must  appeal 


THE    TREATMENT    OF    HIP    DISEASE  97 

to  any  surgeon,  who  sees  much  of  this  class  of  cases,  that 
a  certain  proportion  of  children  do  not  progress  well  under 
treatment  by  the  long  traction  splint.  In  ihe  writer's  expe- 
rience it  has  seemed  to  him  to  be  because  these  children 
have  been  allowed  too  much  joint  motion.  The  cause  of 
most  of  the  complications  is  to  be  found  in  the  ceaseless 
activity  of  such  children,  which  causes  constant  traumatism 
to  the  joint.  They  are  allowed  by  their  parents  in  most 
cases  as  much  activity  as  healthy  children.  They  climb 
fences,  and  jump  rope  continually.  They  run  about  all  day, 
and  indulge  in  all  sorts  of  violent  exercise.  It  stands  to 
reason  that  in  a  joint  which  is  at  all  sensitive,  this  cannot  be 
indulged  in  without  the  risk  of  exciting  joint  irritability  and 
increasing  the  muscular  spasm,  and  such  is  practically  the 
outcome. 

In  hospital  practice  it  is  a  very  common  experience  to 
find  that  the  patient  is  doing  badly,  that  the  joint  is  becom- 
ing sensitive  and  less  movable,  and  that  pain  is  becoming 
marked.  In  these  cases,  it  is  generally  possible  to  find  the 
explanation  of  the  symptoms  in  the  patient's  constant  activ- 
ity. In  certain  cases,  the  severity  of  the  disease  is  enough 
to  account  for  it,  without  further  exciting  causes  ;  but  in  the 
majority  of  cases  the  explanation  of  it  is  to  be  found  in  a 
constantly  repeated  traumatism  of  the  joint. 

It  does  seem,  then,  that  the  lack  of  fixation  afforded  by  the 
traction  splint  is  an  important  element  to  be  considered  in 
the  treatment  of  the  disease ;  and  the  question  arises.  In 
what  way  can  this  matter  be  remedied,  and  in  what  way  can 
greater  quiet  be  secured  to  the  diseased  joint  ? 

In  the  first  place,  the  use  of  crutches  accomplishes  a 
certain  amount  in  this  direction.  If  the  children  wear  so 
high  a  sole  on  the  well  foot  that  the  splint  swings  clear  of  the 
ground  in  walking,  and  are  thus  obliged  to  use  the  crutches 
continually,  much  is  gained.  Again,  a  traction  splint  with 
two  perineal  bands,  and  a  steel  pelvic  band  fitting  accurately 
to  the  pelvis,  is  much  to  be  preferred  to  a  long  traction  splint, 


98 


DISEASES    OF    THE    HIP    JOINT 


which  is  provided  with  only  one  perineal  band,  inasmuch  as 
it  obtains  a  better  hold  of  the  pelvis,  and  affords  better  fixa- 
tion to  the  hip.  Yet  even  this  in  children  who  are  under 
poor  control  is  unsatisfactory,  and  likely  to  yield  poor  re- 
sults. In  such  cases,  the  splint  described  by  the  writer  may 
be  of  use. 


Fig.  27.— COMBINED    FIXATION    AND    TKACTION    SPLINT. 


It  is  practically  a  combination  of  the  Thomas  and  Taylor 
splints.  Embracing  the  thorax  by  a  steel  band,  the  splint 
follows  the  line  of  the  Thomas  splint  as  far  as  the  calf  of  the 

leg,  with  the  exception  that  it  is  provided  at  the  pelvis  with 


THE    TREATMENT   OF    HIP    DISEASE  99 

an  arm  to  encircle  the  pelvis  and  support  the  perineal  band. 
Below  the  calf  of  the  leg  it  terminates  in  a  traction  appliance 
similar  to  that  of  the  traction  splint  described  above. 

The  advantages  of  the  splint  were  stated  as  follows  :  * 
"  It  is  not  presented  as  a  splint  for  the  routine  treatment  of 
hip  disease,  but  as  a  means  of  furnishing  fixation  and  trac- 
tion in  bad  cases,  while  the  patient  goes  about  on  crutches. 
It  has  these  advantages  :  it  necessitates  the  use  of  crutches, 
it  makes  it  impossible  for  the  patient  to  climb  fences  and 
knock  about  in  the  way  so  many  children  do  with  such  dis- 
astrous results,  and  it  makes  it  possible  for  the  child  to  go 
comfortably  about,  even  with  the  joint  exquisitely  sensitive 
to  every  jar." 

Although  this  is  in  general  true,  it  is  not  possible  to  find 
any  appliance  which  it  is  safe  to  use  in  these  extremely  sen- 
sitive cases  without  decided  risk.  Cases  where  sensitiveness 
is  a  marked  feature  demand,  from  the  first,  fixation  in  bed 
until  the  sensitiveness  has  improved. 

In  concluding,  it  may  be  said  that  in  most  cases,  and  in  all 
cases  which  are  under  good  control,  the  long  traction  splint 
affords  a  perfectly  efficient  means  of  treatment,  but  that  in 
unruly  children,  and  in  exceptional  cases,  certain  more  strin- 
gent measures  are  necessary  ;  and  these  will  be  more  fully 
discussed. 

The  Treatment  of  Convalescence. 

When  muscular  rigidity  and  pain  have  subsided  and  have 
been  absent  some  months,  the  question  arises  as  to  abandon- 
ing traction,  and  making  the  first  step  toward  regaining  the 
use  of  the  leg  in  applying  a  simple  protection  splint.  This 
is  a  step  which  should  be  taken  with  much  care  and  deliber- 
ation. Any  precipitancy  is  likely  to  be  regretted,  and  it  is 
often  very  hard  to  wait  what  seems  so  unreasonably  long 
a  time  before  changing  the  splint.     But  the  many  relapses 

*  Trans.  American  Orthopedic  Ass'n,  vol.  i. 


lOO 


DISEASES    OF    THE    HIP    JOINT 


which  occur,  even  when  every  care  has  been  taken  in  mak- 
ing the  change,  should  serve  as  a  warning.  It  must  be 
remembered  that  the  process  is  a  slow  one,  and  that  cure 
most  often  takes  place  by  the  caseation  of  the  tubercular 
foci.  These  remain  latent,  but  ready  to  be  awakened  by  any 
irritation  in  their  neighborhood.  It  is  for  this  reason  that 
it  seems  wise  to  keep  on  for  the  longest  time  possible  the 
most  efficient  splint. 

The  case  shown  in  the  figure  is  one  of  a  series  which  have 

made  the  writer  very  cautious 
about  recommending  a  change  to 
the  convalescent  splint. 

The  boy,  twelve  years  old,  had 
been  under  treatment  with  the 
long  traction  splint  for  three  years, 
and  had  done  well.  As  he  had 
been  for  some  months  without  pain 
or  muscular  spasm  and  was  in  ex- 
cellent condition,  the  traction 
splint  was  removed  and  a  simple 
protection  splint  applied.  His 
good  general  condition  at  that 
time  is  shown  by  the  photograph. 
In  about  three  months  an  old  ab- 
scess cicatrix  broke  down,  pain  be- 
gan to  be  complained  of,  and  in 
the  last  year  the  progress  of  the 
case  has  been  downward  until 
now,  when  it  seems  likely  that 
excision  will  be  necessary.  It 
seemed  as  if  a  quiescent  focus 
had  been  roused  to  activity  by 
the  change  in  splints. 
Reduced  to  its  simplest  terms,  the  protection  splint  is 
merely  the  traction  splint  cut  off  and  attached  to  the  sole  of 
the  boot  instead  of  projecting  below   it.     The  illustrations 


Fig.     28. —  CONVALESCENT      SPLINT 
APPLIED. 


THE    TREATMENT    OF    HIP    DISEASE 


lOI 


will  show  more  plainly  than  any  description  can  do  how 
simply  this  is  accomplished.  The  foot  piece  is  cut  off  and 
the  end  of  the  upright  slotted  to  fit  into  the  arm  from  a  steel 
sole  plate  screwed  to  the  sole  of  the  shoe,  as  shown  in  the 
photographs.  This  supplies  a  perineal  crutch,  which  trans- 
fers the  weight  from  the  hip  joint  to  the  perineum  when  the 
leg  is  used  in  walking. 


Fig.  29. —  CONVALESCENT   SPLINT    FOR    THE    LEFT    LEG    UNAl'l'LIliD    AND    APPLIED. 


In  this  splint  the  patient  is  suspended  by  the  perineal 
strap,  so  that  the  heel  does  not  touch  the  ground  on  the 
affected  side ;  and,  if  the  heel  touches,  the  splint  is  of  course 
inefficient,  and  the  patient  might  as  well  be  without  any 
apparatus  at  all. 


I02 


DISEASES    OF    THE    HIP   JOINT 


In  adults  and  in  older  children,  where  expense  is  not  an 
object,  the  splint  may  be  jointed  at  the  knee,  which  in  no 
way  impairs  its  efficiency,  but  which  adds  to  its  weight, 
although  the  ability  to  bend  the  knee  makes  the  splint  much 
less  cumbersome. 

The  theory  of  the  splint  has  been  very  carefully  worked 
out  by  Dr.  Brackett,*  who  has  demonstrated  very  clearly  the 
reason  for  its  usefulness  in  protecting  the  hip  from  traumat- 
ism. In  normal  walking  the  heel  is  the  first  part  of  the 
foot  to  strike  the  ground  and  receives  the  greater  part  of  the 
shock,  and  the  toe  only  bears  its  share  of  the  pressure  for 
one-sixth  of  the  whole  time.  In  the  first  part  of  the  step 
the  heel  sustains  all  the  weight  of  the  body  at  the  time 
when  the  leof  is  extended. 


Fig.  30. —  NORMAL    PROGRESSION   (bRACKETt) 

By  substituting  the  protection  splint  for  the  unaided  leg, 
the  first  impact  of  the  foot  in  touching  the  ground  is  borne 
by  the  splint  and  transmitted  to  the  perineum  without  com- 
ing at  all  upon  the  hip  joint.  By  means  of  this  the  foot  (and 
consequently  the  hip)  are  protected  from  pressure  except  at 

*  Bost.  Med.  and  Surg.  Journal,  Oct.  6,  1887. 


THE    TREATMENT    OF    HIP    DISEASE 


103 


the  last  part  of  the  step,  when  the  foot  is  in  the  act  of  leav- 
ing the  ground  and  the  least  protection  is  required.  The 
difference  in  the  mechanism  of  locomotion  will  be  appreci- 
ated by  comparison  of  this  diagram  (made  from  photographs 
by  Dr.  Brackett)  with  the  one  preceding. 


Fig.  31. —  PROGRESSION   WITH    THE    PROTECTION    SPLINT  (brACKETT). 


The  Termination  of  Treatment. 

It  is  impossible  to  state  in  general  terms  how  long  the 
convalescent  hip  should  be  protected.  Certainly  for  some 
years  after  the  cessation  of  active  treatment;  perhaps  to  the 
time  of  puberty.  The  question  of  removal  is  a  matter  which 
must  be  decided  for  each  case,  and  there  is  always  the  risk 
of  removing  the  splint  too  soon.  The  active  period  of  the 
disease  is,  in  general,  from  two  or  three  to  five  or  six  years; 
and,  after  that  is  over,  it  must  be  remembered  that  latent 
foci  of  tuberculosis  may  still  be  present,  and  that  all  risk  of 
so  serious  a  matter  as  a  relapse  should  be  avoided.  The 
pathology  teaches  no  lesson  more  clearly  than  that  the 
process   is   in  the  milder  cases  a  very  slow    one. 


I04 


DISEASES    OF    THE    HIP    JOINT 


It  is  not,  of  course,  possible  to  carry  out  such  a  careful 
routine  in  hospital  practice  nor  always  among  the  more  intel- 
ligent classes  ;  but,  if  risk  is  to  be  run  by  an  early  discontin- 
uance of  treatment,  it  would  seem  as  if  the  responsibility 
should  be  taken  by  the  parents  who  desire  it  rather  than 
by  the  surgeon  who  believes  it   to  be  unwise. 


Relapses. 

The  frequency  of  relapses  is  shown  very  well  by  the 
results  of  the  investigation  made  by  Shaffer  and  Lovett  into 
the  ultimate  results  of  the  mechanical  treat- 
ment of  hip  disease.*  Of  51  cases  found 
which  had  been  discharged  "cured"  after  a 
careful  examination,  at  least  four  years  pre- 
vious to  the  search,  6  had  suffered  from  re- 
lapses. These  patients  had  been  under 
treatment  two  and  one-half,  four,  four,  four, 
five,  and  seven  years  respectively.  "  In  one 
case,  the  apparatus  had  been  removed  with- 
out the  knowledge  of  the  surgeon  ;  but  in 
the  five  others  treatment  was  discontinued 
only  after  the  joint  symptoms  had  ceased 
for  some  months,  and  the  patient  could  hop, 
run,  and  perform  other  active  movements 
with  the  affected  leg." 


The  Treatment  of  Double  Hip 
Disease. 

Fortunately,  double  hip  disease  is  an  un- 
common affection  ;  for  the  Treatment  in  any 
event  is  confining  and  distressing,  and  the 
results  apt  to  be  unsatisfactory.  The  dis- 
ease may  be  treated  in  one  of  three  ways. 

{a)  Patients  may  be  treated  by  rest  in  bed 
on  a  bed-frame  with  double  traction.      The 


Fig.  32. — THE  CON- 
VALESCENT SPLINT 
WITH  CURVED  PELVIC 
BAND     APPLIED     (rID- 

lon). 


*  N.Y.  ^led.  Journal,  May  21,  1887. 


THE    TREATMENT    OF    HIP    DISEASE 


105 


only  objection  to  this  method  is  the  prolonged  confinement, 
but  in  the  early  stages  of  the  disease  it  is  to  be  advised 
as  being  more  efficient  than  any  portative  appliance  could  be 
in  the  treatment  of  two  acutely  inflamed  hip  joints.  It  is 
however  often  necessitated  by  the  presence  of  malposition  of 
one  or  both  legs. 

{b)  The  double  Thomas  splint  may  be 
used,  and  affords  an  admirable  means  of 
treatment.  It  fixes  the  trunk  and  limbs  ; 
and,  unless  sensitiveness  be  present,  de- 
manding the  application  of  traction,  the 
method  will  be  found  perfectly  satisfac- 
tory. 

{c)  The  patient  may  be  treated  by  two 
long  traction  splints,  one  on  each  side, 
buckling  together  at  the  waist.  In  the 
writer's  opinion,  this  is  a  little  the  best 
of  the  three  ways  where  practicable,  as  it 
seems  likely  to  secure  a  better  ultimate 
result  than  simple  fixation. 

In  any  event,  it  will  be  possible  for 
the  child  to  get  about  very  little  indeed, 
as  it  is  almost  impossible  to  walk  com- 
fortably or  easily  with  either  of  the  por- 
tative appliances  described  ;  but  they  al- 
low riding  and  out-of-door  air,  and  in 
that  they  have  the  advantage  over  simple  recumbency. 


33. —  THE    DOUBLE    HIP 
SPLINT  (rIDLON). 


The  Treatment  of  the  Complications  of  Hip  Disease. 


The  common  complications  are  :  - 
{g)  Night  cries. 
{h)  Acute  sensitiveness. 
(?)  Malpositions  of  the  limb. 
(j)  Abscesses. 


I06  DISEASES    OF    THE    HIP   JOINT 

(g)  AHgJit  Cries. 

Ordinarily,  night  cries  subside  when  traction  is  applied. 
If  they  persist,  it  will  be  found,  as  a  rule,  that  the  splint  is 
improperly  worn  or  that  the  child  is  going  about  too  much. 
These  causes  are  easily  remedied. 

At  other  times,  in  spite  of  every  care  in  patients  under 
control,  night  cries  will  persist,  generally  in  connection  with 
much  sensitiveness  of  the  joint.  In  these  cases  salicylate 
of  soda  in  full  doses  is  of  much  use.*  Antipyrine  and  phe- 
nacetine  are  sometimes  temporarily  of  benefit.  If  these 
drugs  fail  to  relieve  the  cries,  and  if  the  leg  is  fixed  in  the 
position  of  deformity  and  the  mechanical  treatment  seems  to 
be  properly  carried  out  in  every  way,  it  may  be  useful  to 
elevate  the  leg  slightly.  In  a  case  recently  reported  by 
Goldthwait,  night  cries  were  controlled  in  this  way.f  When 
mechanical  measures  fail  after  faithful  trial,  nothing  but 
operative  measures  remain.  The  head  of  the  femur  may  be 
trephined  through  the  trochanter  or  the  joint  capsule  may 
be  incised  anteriorly  or  posteriorly.  The  latter  measure 
rarely  fails  to  give  relief  for  a  while ;  but  cases  zvhicJi  are 
characterized  by  excessive  sensitiveness  in  the  beginmng  be- 
long, as  a  rnle,  to  the  ivorst  type  of  the  disease,  and  often 
resist  all   measures  of  treatment. 


{h)  Acute  Sensitiveness  of  the  Joint. 

This  condition,  again,  is  commonly  the  result  of  a  fall  or  of 
too  much  activity,  although  often  occurring  without  assign- 
able cause.  Rest  in  bed  is  essential,  and  heavy  traction 
should  temporarily  be  applied ;  and  all  traction  should  be 
made  in  the  line  of  the  leg's  position. 

Salicylate  of  soda  is  often  of  use  ;  and,  if  cases  persist  in 

*  Boston  Med.  and  Surg.  Journal,  April,  1889. 

t  J.  E.  Goldihwait,  Boston  Med.  and  Surg.  Journal,  1S90,  vol.  ii. 


THE    TREATMENT    OF    HIP    DISEASE  lO/ 

spite  of  thorough  mechanical  treatment,  the  joint  should  be 
opened  , 

Acute  attacks  of  sensitiveness,  especially  if  spontaneous, 
are  in  most  cases  the  precursors  of  abscess  formation.  Cer- 
tain cases,  however,  continue  acutely  sensitive  in  spite  of 
every  care  and  in  spite  of  thorough  mechanical  treatment. 

(/)  Malpositions  of  the  Limb. 

At  the  beginning  of  treatment,  in  the  majority  of  hospital 
cases  at  least,  abduction  or  adduction  or  flexion  of  the  dis- 
eased limb  is  present  to  some  degree.  Later  in  the  disease 
these  malpositions  come  on  spontaneously,  or  as  a  result  of 
inefficiency  of  treatment,  or  from  too  much  traumatism  to 
the  joint.  At  other  times  they  come  on  as  sequelae  to  the 
exanthemata  occurring  during  the  course  of  treatment. 

As  a  rule,  malpositions  of  the  limb  are  associated  with  an 
acutely  sensitive  condition  of  the  joint,  and  point,  generally, 
to  some  imperfection  in  the  mechanical  treatment. 

As  soon  as  malposition  reaches  a  degree  which  makes  the 
splint  fit  awkwardly,  or  before  that  if  the  joint  is  acutely 
sensitive,  rest  in  bed  should  be  insisted  upon,  with  traction 
made  in  the  line  of  deformity,  either  by  the  ordinary  traction 
splint  or  by  a  weight  and  pulley.  The  latter  is  generally 
preferable,  and  the  pelvis  should  be  made  square,  and  trac- 
tion made  upon  the  leg  in  whatever  line  it  takes.  It  is 
obvious  that  an  inclined  plane  will  be  necessary  for  this  if 
flexion  is  present.  The  child  should  be  secured  to  a  bed- 
frame  in  every  case,  as  a  measure  necessary  to  secure  proper 
fixation. 

The  figure  (34)  shows  the  application  of  this  method  in  a 
case  of  flexion  with  abduction.  Traction  was  applied  to  the 
well  leg  merely  to  steady  the  patient,  and  is  not  ordinarily 
necessary. 

It  will  be  found  in  the  pursuance  of  this  method  that  at 
very  short  intervals  it  will  be  possible  to  bring  the  leg  nearer 


io8 


DISEASE    OF    THE    HIP    JOINT 


to  a  correct  position,  until  the  normal  line  is  reached.  The 
reduction  of  a  moderate  degree  of  deformity  is  generally  only 
a  matter  of  two  or  three  weeks.  There  is  a  more  forcible  and 
a  quicker  method  of  reduction  by  etherization  and  forcible 
reposition.  This  is,  firstly,  a  rough  shock  to  an  acutely  sen- 
sitive joint,  and  often  causes  much  pain  afterward ;  and, 
secondly,  it  is  occasionally  followed  by  abscess  formation, 
which,  it  will  be  seen  in  the  next  section,  is  in  many  cases 
avoided  by  the  milder  method  of  deformity  correction.      If 


Fig.  34. —  BED  TRACTION  IN  A  CASE  OF  FLEXION  AND  ABDUCTION. 

the  leg  is  forcibly  straightened,  a  plaster  spica  should  be 
applied,  while  the  patient  is  unconscious,  to  hold  what  has 
been  gained  in  the  position  of  the  diseased  leg. 

The  method  of  Dr.  Taylor  for  the  correction  of  adduction 
is  exemplified  in  the  cut.  It  consists  in  a  hip  splint  applied 
in  a  reversed  position,  so  that  the  perineal  band  presses 
in  the  groin  of  the  healthy  side.  In  this  way  forcible  lev- 
erage is  obtained,  which  tends  to  straighten  the  leg.  The 
splint  is  applied  during  recumbency  only. 

In  many  cases  the  choice  of  a  method  will  have  to  be 
dictated  by  the  circumstances  of  the  patient ;  and  forcible 
reposition  is  a   perfectly  legitimate    proceeding  where  it  is 


THE    TREATMENT    OF    HIP    DISEASE 


109 


desirable  to  save  time  or  where  good  home  or  hospital  care 
is  not  obtainable. 

If  anchylosis  occur  in  a  deformed  position,  operative  meas- 
ures must  be  resorted  to. 

When  an  anchylosis  of 
the  hip  has  occurred  in  a 
position  of  much  deform- 
ity, several  operative 
measures  are  to  be  con- 
sidered which  have  been 
of  use  in  the  rectification 
of  the  deformity.  If  the 
anchylosis  is  bony,  any- 
thing short  of  a  cutting 
operation  is  not  likely  to 
be  of  use  ;  but  the  for- 
mation of  a  true  bony 
anchylosis  is  a  matter  of 
some  years  probably,  and 
many  anchyloses  appar- 
ently firm  and  osseous 
are  in  reality  only  fi- 
brous. It  is  a  question 
whether  it  is  better  to 
operate  upon  a  recent 
anchylosis  or  to  wait 
until  the  local  condition 
has  quieted  down,  and 
then  to  do  one  of  the 
cutting  operations  to  be 
described. 

If  it  is  decided  to  operate  upon  a  recent  anchylosis,  the 
most  common  method  is  that  of  brisement  force.  The 
patient  is  etherized,  and  the  hip  is  forcibly  extended  over 
the  edge  of  the  table,  or  by  laying  the  patient  on  the  face 
and  crowding  the  pelvis  downward,  so  as  to  obliterate  the 


Fig- 3S- — Taylor's  splint  for  the  correction 

OF   ADDUCTION. 


no  DISEASES    OF    THE    HIP   JOINT 

angle  between  the  trunk  and  the  femur.  It  is  hardly  neces- 
sary to  call  attention  to  the  fact  that  a  proceeding  of  this 
sort  is  likely  to  start  up  any  latent  focus  of  tuberculosis  which 
may  exist  in  the  joint,  and  that,  in  a  certain  proportion  of 


pjg_    2,5. —  SEVERE    FLEXION    OF    THE    UISEASEL)    LEG   IN    H[P   DISEASE   (AN    UNTREATED    CASe), 
NECESSITATING   RECUMBENCY   IN    BED. 

cases,  it  is  followed  by  an  active  outbreak  of  the  disease.  In 
acute  stages  of  hip  disease  this  proceeding,  or  forcible  exten- 
sion of  the  hip,  is  not  one  of  any  great  risk,  although  inferior 
to  the  method  by  recumbency ;  but,  after  the  acute  stage  of 
the  disease  is  over,  it  seems  to  the  writer  an  unjustifiable 


THE    TREATMENT    OF    HIP    DISEASE  III 

risk  to  run  for  the  surgeon  to  adopt  any  proceeding  which 
is  at  all  likely  to  again  start  up  the  acute  disease.  Con- 
sequently, in  the  writer's  opinion,  it  is  wiser  and  safer,  in 
cases  where  anchylosis  has  occurred  in  a  deformed  position, 
to  wait  until  the  local  condition  is  quiet,  probably  a  matter 
of  months  or  years,  before  proceeding  to  any  operation,  and 
then  to  do  a  thorough,  cutting  operation  about  to  be  de- 
scribed. 

One  or  two  other  proceedings  should  be  mentioned  before 
speaking  of  •  the  common  operation  for  the  correction  of 
anchylosis  in  deformity.  In  certain  cases  even  when  oste- 
otomy has  been  performed,  and  in  other  cases  where  the  an- 
chylosis is  only  fibrous,  there  is  so  much  contraction  of  the 
skin  and  fasciae  at  the  anterior  part  of  the  thigh  that  it  is 
impossible  to  extend  the  leg  without  dividing  the  structures. 
Consequently,  tenotomy  and  myotomy  are  occasional  proced- 
ures, either  alone  or  in  connection  with  osteotomy. 

Osteoclasis  is  occasionally,  although  very  rarely  in  these 
days,  used  as  a  means  of  correction  for  hip  deformity.  The 
operation  lacks  precision,  and  its  interest  is  chiefly  historical. 
Very  rarely  it  is  done  by  manual  force,  and  most  often  by 
one  of  the  osteoclasts  for  the  purpose. 

Subtrochanteric  Osteotomy. — The  most  common  and  the 
most  useful  operation  for  hip  deformity  is  subtrochanteric 
osteotomy  as  performed  by  the  method  of  Mr.  Gant.  The 
only  other  operation  is  that  of  Adams,  which  is  a  supra- 
trochanteric  osteotomy  of  the  neck  of  the  femur.  The 
advantage  of  the  operation  below  the  trochanter  minor  is 
that  relapse  is  less  likely,  on  account  of  the  division  of  the 
bone  below  the  insertion  of  the  psoas  muscle.  If,  as  in  Mr, 
Adams's  operation,  it  is  done  above  the  trochanter  minor, 
the  continued  pull  of  the  muscles  inserted  into  it  is  a 
factor  which  is  likely  to  reproduce  the  flexion.  The  reason 
for  the  preference  of  subtrochanteric  osteotomy  is  given  by 
Mr.  Gant  (British  Medical  Journal,  Oct.  i8,  1879)  :  — 

"When,  in  consequence  of  continued  disease  of   the  hip 


112  DISEASE    OF    THE    HIP    JOINT 

joint,  the  head  of  the  femur  has  disappeared,  leaving  only  a 
stunted  nodule  of  bone  representing  the  neck  above  the  tro- 
chanter, in  such  a  case  the  operation  of  section  in  the  fem- 
oral neck  cannot  be  performed,  there  being  no  neck  to 
divide.  Even  when  supratrochanteric  section  is  practicable 
the  state  of  the  neck  may  render  this  operation  abortive. 
The  seat  of  the  operation  will  be  in  an  almost  carious  por- 
tion of  bone,  which  is  unfit  to  yield  a  fibrous  union." 

It  is  for  these  reasons,  and  on  account  of  its  simplicity, 
that  Mr.  Gant's  operation  is,  in  the  writer's  opinion,  prefer- 
able to  any  other  for  the  correction  of  hip  deformity.  The 
risk  of  the  operation  is  very  slight. 

Poore  analyzed  167  cases  of  osteotomy  about  the  upper 
end  of  the  femur.  Of  these,  138  were  cured,  17  died,  and  12 
were  failures.  Of  the  17  fatal  cases,  12  occurred  before  the 
advent  of  antiseptic  surgery.  These  figures  are  not  in  any 
way  representative,  and  exaggerate  very  much  the  danger  of 
the  operation.  So  far  as  the  writer's  personal  experience 
has  gone,  the  operation  has  been  always  simple,  and  unat- 
tended by  unpleasant  symptoms  ;  and  he  has  never  person- 
ally heard  of  any  trouble  occurring  in  the  operation,  as  per- 
formed in  the  last  few  years. 

The  operation  is  done  very  simply,  and  every  possible 
antiseptic  precaution  should  be  observed.  The  patient  is 
etherized  and  turned  upon  the  side,  and  the  incision  may  be 
made  exposing  the  trochanter  if  it  is  desired,  although  it 
seems  entirely  unnecessary,  and  the  operation  is  less  bloody 
if  the  chisel  is  driven  directly  into  the  bone  through  the 
sound  skin.  The  place  selected  for  section  should  be  an 
inch  or  an  inch  and  a  half  below  the  great  trochanter,  and 
the  section  should  be  made  across  the  long  axis  of  the  bone. 
When  it  is  evident  that  the  bone  is  very  nearly  divided,  and 
that  only  a  shell  is  left,  the  femur  should  be  fractured  by 
gentle  force,  preferably  bending  the  bone  inward.  The 
bone  breaks  with  a  loud  snap,  and  in  most  cases  the  leg  can 
be  immediately  placed  in  a  correct  position. 


THE    TREATMENT    OF    HIP    DISEASE 


113 


In  some  cases  of  long  standing,  division  of  the  soft  parts 
over  the  anterior  surface  of  the  thigh  may  be  necessary,  as 
has  been  said.  An  antiseptic  dressing  should  be  applied, 
and  the  patient  is  most  easily  cared  for  on  a  bed-frame,  with 
traction  applied  to  the  leg  which  has  been  operated  upon. 

A  plaster  spica  is  dirty  and  uncomfortable,  and  the  leg 
cannot  be  inspected  without  a  good  deal  of  disturbance  of 
the  patient.  It  should  be  re- 
membered that  the  operation 
produces  a  compound  fracture 
of  the  femur,  and  that  con- 
finement to  bed  is  necessary 
for  about  six  weeks,  beginning 
with  a  gradual  use  of  the  leg. 
A  too  early  use  of  the  leg  is 
likely  to  be  attended  by  a  re- 
lapse and  by  fle.xion  of  the 
leg.  If  abduction  or  adduc- 
tion exist,  they  are  easily  rec- 
tified at  the  time  of  opera- 
tion ;  and,  in  one  or  two  in- 
stances coming  under  the 
writer's  observation,  the  op- 
eration has  been  done  chiefly 
to  correct  a  lateral  curvature 
which  was  beginning,  and 
which  seemed  to  be  due  to 
the  obliquity  of  the  pelvis 
caused  by  adduction  of  the 
diseased  leg. 

The  question  of  the  advisa- 
bility of  the  operation  is  one 
which  must  be,  of  course,  settled  in  each  case.  As  a  rule, 
when  the  deformity  is  severe  enough  to  cause  a  very  con- 
spicuous limp,  or  is  enough  to  disable  the  patient  by  causing 
lateral  curvature,  or  on  account  of  its  marked  characteristics, 


Fig-  37- — A  ISAU  RESULT  KKOM  HIP  DIS- 
EASE DUE  TO  ANCHYLOSIS  IN  THE  POSITION 
OF    DEFORMITY. 


114  DISEASES    OF    THE    HIP    JOINT 

it  is  proper  to  recommend  the  operation.  It  is  performed 
equally  well  upon  children  and  adults,  and  is  to-day  done 
almost  to  the  exclusion  of  all  other  similar  operations. 


(_/')  Abscesses. 

The  occurrence  of  abscesses  is  in  many  cases  due  to  the 
severity  and  destructive  character  of  the  disease  in  the  indi- 
vidual case,  but  in  most  instances  it  is  the  result  of  inefh- 


Fig.  38. —  A    HIP    ABSCESS. 

cient  or-incomplete  treatment.  The  joint  being  imperfectly 
protected  or  fixed,  irritation  of  the  articular  surfaces  is  in- 
duced by  constant  traumatism,  which  is  expressed  first  by 
increased  muscular  spasm  and  malposition  of  the  limb,  and 
then  by  the  formation  of  pus  in  large  quantities,  which  bursts 


THE    TREATMENT    OF    HIP    DISEASE  II5 

through  the  weakened  capsule  and  seeks  the  surface, —  some- 
times on  the  anterior  surface  of  the  thigh,  at  other  times  in 
the  buttock,  or  still  more  uncommonly  under  the  adductor 
tendons.  Although  no  definite  conclusions  as  to  the  seat 
and  character  of  the  disease  can  be  drawn  from  the  location 
of  the  abscess,  those  appearing  at  the  inside  of  the  leg  under 
the  adductor  tendons  are  more  likely  to  be  associated  with 
pelvic  disease  and  to  be  more  troublesome.  The  appearance 
of  an  ordinary  hip  abscess  is  well  indicated  in  the  figure. 

Widely  differing  views  are  held  in  regard  to  the  treatment 
of  hip  abscesses  by  American  orthopedic  surgeons.  In 
Europe  it  is  the  universal  practice  to  incise  such  collections 
of  pus,  and  for  that  matter  such  is  the  practice  of  most 
American  orthopedists.  But  the  fact  that  Dr.  N.  M.  Shaffer 
and  Dr.  Judson,  of  New  York,  stand  as  the  representatives 
of  a  few  men  who  advise  against  operation,  makes  a  careful 
consideration  of  the  question  necessary. 

Dr.  Judson  has  formulated  the  objections  to  operation  : 
"  Incision  is  a  tardy  and  fruitless  procedure.  The  painful 
stage  in  the  history  of  the  abscess  is  long  past.  It  was 
present  when  the  pus  was  collecting  under  the  periosteum 
and  in  the  cells  of  the  bone.  .  .  .  But,  when  the  pus  is  in  the 
cellular  structures  or  the  cavity  of  the  joint,  I  do  not  see 
that  the  progress  of  the  case  can  be  materially  affected  by 
interference." 

"  If  we  operate,  we  substitute  artificial  for  natural  closure; 
and,  with  the  best  antisepsis,  we  gain  nothing  by  operating 
unless  we  reach  and  scrape  out  the  purulent  deposit  or  the 
interior  of  the  joint.  .  .  .  And,  if  we  operate  in  the  manner 
described,  we  do  not  avoid  the  necessity  of  bringing  to  bear 
the  best  mechanical  treatment  and  hygienic  control,  which, 
if  they  are  supplied,  will  bring  about  a  recovery,  whether  we 
operate  or  not,  by  the  slow  but  sure  process  of  natural  re- 
pair, with  the  better  result  the  less  we  interfere  with  the 
soft  parts,  as  a  general  rule."  * 

*  New  York  Med.  Journal,  March  2,  1889. 


Il6  DISEASES    OF    THE    HIP    JOINT 

Dr.  Judson  had  expressed  similar  views  in  1885,  with 
regard  to  which  Dr.  L.  A.  Sayre  said  in  the  discussion  that 
"it  was  a  disgrace  to  the  orthopedic  surgery  of  America  to 
allow  such  statements  to  go  abroad  uncontradicted."  * 

These  views  of  Dr.  Judson  represent  the  best  that  can  be 
said,  presumably,  of  non-operative  treatment  ;  and  the  fact 
that  he  and  Dr.  Shaffer  advocate  such  treatment  should  not 
be  estimated  too  lightly.  In  favor  of  the  non-operative 
treatment  it  may  be  said,  further,  that  absorption  of  ab- 
scesses occasionally  occurs  at  even  an  advanced  stage,  when 
fluctuation  is  plainly  to  be  felt  ;  that  any  operation  is  at- 
tended by  the  risk  of  accidents  resulting  in  death ;  and 
that,  although  there  should  be  no  risk  of  septicaemia  from 
operation,  there  is,  as  after  excision  of  the  joint,  a  slight  risk 
of  the  generalization  of  tuberculosis,  undoubtedly  by  infec- 
tion at  the  site  of  the  incision. 

The  conservative  treatment  of  abscess  in  hip  disease 
should  be  limited  to  cases  under  good  control,  where  an 
abscess  is  not  painful  and  shows  no  tendency  to  increase  ; 
where  its  spread  can  be  limited  by  bandaging  or  the  press- 
ure of  the  anterior  pad-plate  of  the  splmt,  and  its  growth 
will  be  toward  the  surface  instead  of  laterally  between  the 
layers  of  fascia.  In  such  cases  there  is  no  impropriety  in 
waiting  almost  indefinitel}'  in  the  hope  that  the  abscess  ma\' 
be  absorbed. 

In  cases  where  perfect  antisepsis  is  not  obtainable,  it  is 
better  to  allow  the  abscess  to  burst,  as  also  in  the  case  of 
unusually  delicate  and  nervous  children,  where  the  abscesses 
are  not  painful. 

In  short,  the  non-operative  treatment  of  painless  hip 
abscess  is  sanctioned  bv  the  best  authority,  but,  in  the 
minds  of  most  surgeons,  is  inferior  to  the  treatment  about 
to  be  considered,  and,  so  far  as  the  writer's  experience  goes, 
should  be  limited  to  the  class  of  cases  just  described. 

*  New  Vork  Med.  Journal.  Jan.  31,  18S5,  p.  116. 


THE    TREATMENT    OF    HIP    DISEASE  II 7 

The  Prevention  of  Hip  Abscess. —  It  may,  however,  first 
be  permissible  to  speak  of  the  prevention  of  hip  abscesses 
as  a  most  important  part  of  the  discussion  of  their  treatment. 

The  percentage  of  cases  in  which  they  occur  varies  very 
widely.  In  the  cases  reported  by  the  London  Clinical 
Society,  in  1880,  of  401  cases,  69  per  cent,  developed  ab- 
scesses. Mr.  Howard  Marsh,  in  an  analysis  of  cases  since 
1880  from  the  Alexandra  Hospital,  found  abscesses  in  only 
50  per  cent,  which  diminution  he  attributed  to  improved 
methods  of  treatment.  Gibney  reported,  in  1878,  80  cases 
of  cured  hip  disease,  60  per  cent,  of  which  had  developed 
abscesses.  Mr.  Marsh  said,  in  speaking  of  his  cases,  "  My 
own  estimate,  from  what  I  have  seen  in  the  hospital  and 
elsewhere,  is  that  the  formation  of  an  abscess  may  be 
averted  in  at  least  80  per  cent,  of  the  total  number  of 
cases." 

In  contrast  to  these  percentages,  the  series  of  cases  re- 
ported by  Lovett  and  Goldthwait  *  is  of  much  interest.  In 
320  cases  under  treatment  at  the  Children's  Hospital  in  Bos- 
ton, only  some  75  developed  abscess,  making  a  percentage  of 
only  23,  which  is  very  strikingly  less  than  any  other  series 
of  cases,  and  seems  to  fulfil  Marsh's  prediction.  More  re- 
cently the  writer  has  had  the  opportunity  of  investigating  a 
still  larger  number  of  cases,  including  those  just  mentioned. 

From  1884  to  1890,  inclusive,  there  presented  themselves 
at  the  Out-patient  Department  of  the  Children's  Hospital 
574  new  cases  of  hip  disease.  In  pursuance  of  the  operative 
treatment  of  these  abscesses  which  has  been  followed  out 
for  some  years,  practically  all  cases  of  abscesses  were  ad- 
mitted to  the  hospital  wards  as  soon  as  they  appeared.  In 
those  years  when  574  new  cases  appeared  at  the  Out-patient 
Department,  107  abscesses  were  opened  in  the  hospital, 
which  means  that  107  cases  either  had  an  abscess  at  the 
time  of  coming  or  developed  it  in  the  course  of  the  disease. 
This  gives  a  percentage  of   18.7  per  cent.,   which    is  very 

*  Trans.  Am.  Orth.  Ass'n,  vol.  ii.  p.  82. 


Il8  DISEASES    OF    THE    HIP    JOINT 

much  lower  than  in  any  other  series  of  cases  reported. 
There  may  be  a  sHght  error,  amounting  to  i  or  2  per  cent., 
caused  by  exceptional  cases  of  abscesses  which  were  not 
operated  upon  ;  but  these  were  so  few  that  they  would  make 
very  little  difference  in  the  percentage. 

The  reason  for  this  small  percentage  is  believed  by  the 
writer  to  be  due  to  the  fact  that  cases  under  ambulatory 
treatment  are  at  once  admitted  to  the  hospital  whenever 
sensitiveness  or  deformity  of  the  joint  occurs,  and  are 
treated  by  recumbency. 

In  1 888,-  42  cases  of  hip  disease  were  admitted  to  the 
ward;  in  1889,  59  cases;  in  1890,  81  cases.  In  these  years 
the  percentage  of  cases  admitted  for  deformity  and  sensi- 
tiveness has  steadily  increased,  and  the  percentage  of  cases 
admitted  for  abscess  has  steadily  diminished.  Of  the  182 
patients  admitted  in  these  three  years  (which  are  all  that  it 
has  been  possible  to  analyze),  107  were  admitted  for  deform- 
ity or  sensitiveness,  and  stayed  only  a  short  time  in  the 
hospital,  returning  to  the  Out-patient  Department  for  ambu- 
latory treatment,  while  only  54  cases  were  admitted  for 
abscess  and  23  for  application  of  apparatus. 

It  seems  reasonable,  therefore,  to  conclude  that  the  con- 
finement of  the  patient  to  bed  during  the  occurrence  of 
deformity  or  sensitiveness  of  the  joint  is  a  measure  which 
renders  the  occurrence  of  abscess  less  likely,  and  is  to 
be  regarded  as  preventive  treatment.  When  the  abscesses 
occur,  three  courses  are  open, —  the  abscess  may  be  let 
alone,  it  may  be  aspirated,  or  it  may  be  incised.  In  general, 
as  has  been  said,  it  may  be  let  alone  so  long  as  it  does  not 
increase,  or  when  the  circumstances  of  the  patient  demand 
it.  Personally,  the  writer  is  in  favor  of  early  and  thorough 
operative-treatment,  at  least  in  hospital  cases;  but  it  should 
be  stated  clearly  that  it  is  a  personal  preference,  and  that 
expectancy  is  admissible  and  to  be  considered  good  treat- 
ment. 

Treatment  by  Aspiration. —  Methods  of  treatment  by  aspi- 


THE    TREATMENT    OF    HIP    DISEASE  II9 

ration  are,  as  a  rule,  unsatisfactory.  These  abscess  cavities 
are  lined  by  a  pyogenic  membrane,  which  will  secrete  more 
pus  when  the  contents  are  drawn  off ;  and  attempts  to  check 
its  activity  by  the  injection  of  solutions  of  iodoform  or  car- 
bolic acid  are,  to  say  the  least,  attended  with  danger. 
There  is  on  record*  the  death  of  a  child  where  1-40  car- 
bolic acid  was  used  in  this  way.  Very  rarely  aspiration  is 
effective.  The  writer  recalls  a  case  of  extensive  abscess  at 
the  inner  side  of  the  leg  where  the  parents  and  child  were 
so  excessively  nervous  that  operation  was  not  possible,  and 
where  the  distention  was  so  great  that  much  delbrmity  was 
caused.  The  abscess  was  aspirated  over  a  year  ago  as  a 
palliative  measure,  and  refilled  temporarily  to  a  slight  ex- 
tent, after  which  it  entirely  disappeared.  Such  an  experi- 
ence as  this  seemed  so  rare  that  it  deserved  notice.  Yet 
within  the  last  few  months,  one  year  after  aspiration,  this 
abscess  has  refilled  and  has  broken  externally.  This  has 
been  the  invariable  experience  of  the  writer  in  the  aspira- 
tion of  abscesses. 

Treatment  by  Incision. —  In  general,  if  operative  measures 
are  to  be  undertaken,  free  incision  will  be  found  the  most 
satisfactory  and  thorough.  The  abscess  should  be  opened 
throughout  its  whole  extent  and  thoroughly  irrigated.  The 
pyogenic  membrane  should  then  be  thoroughly  scraped  off 
of  the  abscess  walls  with  a  sharp  spoon,  and  the  cavity  dried 
with  sponges.  The  general  plan  is  to  insert  a  drainage  tube 
and  apply  an  antiseptic  dressing,  but  this  is  practically  sure 
to  leave  a  sinus.  The  same  may  be  said  of  packing  the 
wound  with  gauze.  The  writer  f  has  reported  several  cases 
of  hip  abscess  where,  after  incision  and  drying  of  the  wound, 
the  line  of  incision  was  tightly  sewed  up  without  any  drain- 
age whatever.  In  these  cases,  union  by  first  intention 
occurred,  and  much  discomfort  and  inconvenience  were 
avoided  by  having  done  away  with   a  sinus. 

*  Bradford  and  Lovett,  Orthopedic  Surgery,  iSgo,  p.  326. 
t  Bost.  Med.  and  Surg.  Journal,  Sept.  18,  1890. 


I20 


DISEASES    OF    THE    HIP    JOINT 


The  writer  has  operated  more  recently  upon  several  cases 
by  this  method,  and  has  obtained  a  large  proportion  of  suc- 
cesses. Sometimes  the  wound  at  once  breaks  down  and  a 
sinus  forms,  or  the  cicatrix  may  give  way  when  the  stitches 
are  removed;  but  in  most  cases  firm  union  is  obtained  by 
first  intention,  and  in  cases  operated  upon  two  years  ago  the 
cicatrix  is  still  firm  and  normal.  The  experience  with  regard 
to  drainage  tubes  at  the  Boston  Children's  Hospital  is  of 
interest :  "  Of  43  cases  of  abscess  of  the  hip  operated  on  at 
the  Children's  Hospital  between  1884  and   1888,  only  one  is 


Fig.  39. —  HIP   ABSCESS   INXISED    AND   SEWED    UP.       THERE    IS    NOW    A    FIRM,    HARD    CICATRIX. 


recorded  as  having  healed  within  six  months,  and  about  half 
of  the  sinuses  healed  within  periods  varying  from  one  to  two 
years,  the  rest  remaining  open  almost  indefinitely.  These 
cases  were  all  thoroughly  cleaned  out  after  a  free  incision, 
and  were  either  packed  with  gauze  or,  more  commonly, 
drainage  tubes  were  inserted  and  an  antiseptic  dressing 
applied.  .'.  .  The  site  of  the  drainage  tube  was  almost  always 
the  site  of  a  sinus  which  persisted  for  a  varying  period  of 
time."  There  is  a  similar  advocacy  of  treating  abscess  with- 
out drainage  in  the  Practitioner  for  February,  1890. 


THE    TREATMENT    OF    HIP    DISEASE 


121 


If  this  method  is  to  be  pursued,  the  strictest  antisepsis 
and  asepsis  are  essential ;  and,  if  there  is  reason  to  suspect 
the  thoroughness  of  either  of  these,  it  is  better  not  to  oper- 
ate, or  at  all  events  to  leave  the  abscess  cavity  open.  It  is 
better  to  leave  the  incision  open  in  cases  where  there  is 
much  inflammatory  exudation  into  the  tissues  around  the 
abscess,  in  cases  which  are  particularly  acute,  and  in  very 
extensive  abscess  cavities.  In  many,  in  fact  in  most,  of  the 
writer's  cases  which  healed  bv  first  intention,  communication 


Fig.  40. —  HIP    ABSCESS   OF  GREAT   EXTENT,    INCISED    AND    SEWED    UP    THREE    WEEKS    PREVIOUS 
TO    PHOTOGRAPH.      CICATRIX   IS    FIRM,    AND   TISSUES    ARE    NOT    INDURATED 
OR    FLUCTUATING. 


of  the  abscess  with  the  joint  cavity  was  demonstrated  at  the 
operation,  so  that  this  cannot  be  accepted  as  a  contra-indica- 
tion  to  suture. 

A  change  in  the  mortality  at  the  Alexandra  Hospital  in 
late  years  is  attributed  by  Mr.  Marsh  to  the  fact  that  of  late 
years  the  abscesses  have  been  opened  and  drained,  whereas 
in  former  years  this  was  not  the  case.  There  are  two  series 
of  cases  from  which  this  inference  is  drawn, —  those  prior  to 
1880  reported  by  the  Clinical  Society,  where  the  mortality 
was  30.4 9ic  in  the  suppurating  cases  and  7%  in  the  others, 


122  DISEASE    OF    THE    HIP    JOINT 

while  in  a  series  of  614  cases  since  that  time  reported  by 
Mr.  Marsh  the  mortality  was  6%  only. 

If  suture  is  to  be  attempted,  the  abscess  should  be  incised 
from  top  to  bottom,  no  matter  how  long  a  cut  is  made. 
The  pyogenic  membrane  should  be  scraped  out  with  a 
curette,  reaching  to  every  corner  of  the  wound.  The  cavity 
should  then  be  scrubbed  with  dry  sponges,  and  packed  with 
them  until  bleeding  is  stopped.  Then,  after  the  wound  is 
dusted  with  iodoform,  it  should  be  tightly  sewed  up,  and  a 
heavy  antiseptic  dressing  applied,  which  should  not  be  dis- 
turbed for  ten  days,  unless  there  is  discomfort  or  elevation 
of  temperature. 

The  reasons  that  lead  the  writer  to  advocate  the  early 
operative  treatment  of  abscess  are  these  :  If  a  careful  and 
rigorous  treatment  is  carried  out,  abscesses  will  only  appear 
in  a  small  proportion  of  cases,  and  these  will  be  cases  of 
exceptional  severity.  Under  these  circumstances,  joint 
drainage  will  be  of  benefit,  and  waiting  for  the  absorption 
of  the  abscess   will  in   general   prove  futile. 

In  such  cases,  abscess  formation  is  generally  associated 
with  pain  in  the  joint  and  a  condition  of  acute  sensitiveness. 
This  is  generally  at  once  relieved  by  incision  of  the  abscess, 
just  as  in  similar  cases,  without  abscess  formation,  joint 
incision  is  sometimes  necessary. 

And,  finally,  the  general  surgical  principles  which  demand 
the  evacuation  of  pus  influence  the  writer  here,  as  in  other 
parts  of  the  body,  to  evacuate  it,  when  present  in  more  than 
a  small  amount  ;  and  not  the  least  consideration  should  be 
the  possibility  in  a  certain  proportion  of  cases  of  securing 
evacuation  of  the  contents  of  the  abscess  with  an  almost 
immediate  closure  of  the  wound,  avoiding  the  formation  of 
sinuses.' 

After  the  incision  of  abscesses,  rest  in  bed  is  temporarily 
indicated  until  the  effects  of  the  operation  are  recovered 
from.  Generally,  in  two  or  three  weeks  the  incision  will 
have  firmly  healed  up  (if  sewed  up  tightly)  or  a  well-defined 


THE    TREATMENT    OF    HIP    DISEASE  I23 

sinus  will  have  been  formed  where   the  drainage  tube  was 
inserted. 

No  treatment  seems  to  be  of  much  use  in  causing  the 
closure  of  such  sinuses.  At  times  it  has  seemed  to  the 
writer  that  some  benefit  was  derived  from  the  insertion 
every  two  or  three  days  of  a  urethral  iodoform  bougie,  about 
iV  of  an  inch  in  diameter,  containing  from  three  to  five 
grains  of  iodoform  in  cocoa  butter.  In  general,  however, 
these  sinuses  run  for  some  months,  and  their  spontaneous 
closure  is  a  most  favorable  prognostic   sign. 

Resume  of  the  Treatment  of  Hip  Disease. 

It  is  very  hard  to  summarize  so  extensive  a  subject  as  the 
treatment  of  hip  disease ;  yet,  after  so  extended  a  considera- 
tion of  the  subject,  the  writer  is  anxious  once  more  to  de- 
clare his  belief  that  the  best  treatment  for  hip  disease  is  to 
be  found  in  the  traction  treatment,  combined  with  measures 
which  are  calculated  to  secure  a  large  degree  of  rest  to  the 
affected  joint. 

This  plan  would  consist  in  the  application  of  a  long  trac 
tion  splint,  and  necessitates  the  use  of  crutches  and  a  high 
shoe.  This  splint  should  be  worn  night  and  day  until  some 
months  after  the  cessation  of  all  muscular  spasm.  Sensi- 
tiveness of  the  joint  and  the  occurrence  of  malposition  are 
indications  for  rest  in  bed.  The  activity  of  children  treated 
in  this  way  should  be  restricted  by  recumbency  for  two 
hours  or  more  a  day  and  by  most  careful  watching. 

In  short,  the  writer  would  be  glad  to  advocate  in  every 
way  the  necessity  of  greater  joint  rest  in  connection  with 
the  ambulatory  traction  treatment. 

II.     The  Operative  Treatment  of  Hip  Disease. 

Excision  of  the  Hip. 

The  operative  treatment  of  hip  disease  is  generally  in- 
terpreted to  mean  treatment  by  excision  of  the  joint.     Cer- 


124  DISEASES    OF    THE    HIP   JOINT 

tain  minor  operative  procedures  will  be  considered  later. 
These  are  ignipuncture,  incision  of  the  joint,  trephining  the 
neck  of  the  femur,  etc. 

Considering,  then,  the  operative  treatment  of  the  disease 
as  contrasted  with  the  mechanical  treatment,  two  questions 
arise.  First,  Does  operation  diminish  the  death-rate  of  the 
disease  }  Second,  Are  the  results  better  after  operation 
than  after  mechanical   treatment .-' 

It  may  be  stated  here  that  the  advocates  of  excision  as 
a  treatment  for  hip  disease  are  to  be  found  among  German 
and  English  writers  ;  while  American  orthopedic  surgeons 
unite  in  advocating  excision  only  as  a  last  resort,  to  be  used 
when  mechanical  treatment  has  failed. 

Excision  of  the  hip  joint  is  a  serious  operation,  and  should 
only  be  undertaken  with  (a)  the  hope  of  lowering  the  mor- 
tality of  the  disease,  (d)  in  order  to  prevent  systemic  infec- 
tion (a  generalization  of  the  local  tuberculosis),  and  (c)  to 
obtain  better  functional  results  than  by  mechanical  means. 

(a)  TJie  Mortality  after  Excision. —  Mr.  Wright,  of  Man- 
chester,* has  collected  2,461  cases  of  hip  excision,  new  and 
old,  done  with  and  without  antisepsis,  and  finds  1,566  re- 
coveries and  841  deaths,  which  amounts  to  34  per  cent,  of 
mortality.  The  older  groups  of  cases  give  a  higher  death- 
rate,  Leisrink's  t  being  63.6  per  cent,  and  Culbertson's  41.6 
in  418  cases.  Caumont  %  divided  his  cases  into  two  groups  ; 
and  he  found  that  without  antisepsis  the  mortality  was  66 
per.  cent.,  while  with  antiseptic  precautions  it  fell  to  41  per 
cent. 

The  time  at  which  the  resection  is  done,  of  course,  is  an 
important  factor  in  determining  its  gravity.  Grosch  §  an- 
alyzed 166  cases,  and  he  divided  them  into  classes  according 
to  the -stage  of  the  disease  at  which  they  were  done.  In 
the  first  stage  in  children  (where  the  suppuration  has  not 
reached  the  surface)  the  per  cent,  of  mortality  was  zero,  in 

*  G.  A.  Wright,  Hip  Disease  in  Childhood.  t  Archiv  f.  Klin.  Chir.,  xii.  177. 

i  Caumont,  Deutsch.  z.  f.  Chir.,  xx.,  1SS4,  p.  344.     §  Cent.  f.  Chir.,  1SS2,  xiv.  229. 


THE    TREATMENT    OF    HIP    DISEASE  125 

the  second  class  (those  with  extensive  suppuration)  it  was 
24.1  per  cent.,  and  in  the  third  and  last  class  of  advanced 
disease  it  was  67.5   per  cent. 

As  representative  of  the  results  obtained  under  modern 
conditions,  Bradford  and  Lovett  give  the  following  table:  — 

Cases.  Mortality  per  Cent. 

Volkmann, 48  25.30 

Korff, 33  48.5 

Grosch, 166  36.7 

Alexander, .  36  30.5 

It  is  not  to  be  supposed  that  these  writers,  nearly  all  of 
whom  are  advocates  of  excision  of  the  hip,  have  reported  any 
cases  as  deaths  besides  those  which  are  legitimately  to  be 
attributed  to  the  operation.  The  later  cases  of  death,  in 
most  instances,  are  not  counted  as  due  to  the  operation. 

So  that  the  outcome  of  the  matter  is  that  excision,  as 
ordinarily  performed,  carries  with  it  a  mortality  per  cent,  of 
30  or  more  ;  and  this  seems  a  serious  risk  to  assume,  unless 
it  becomes  evident  that  decided  benefit  is  to  ensue  over 
any  other  method.  That  matter  will  come  up  for  discussion 
later. 

{b)  Excision  has  been  advocated  as  a  preventive  of  gen- 
eralization of  tuberculosis  from  the  focus  in  the  hip.  That 
such  a  danger  exists  is  well  known. 

In  a  series  of  cases  at  the  Alexandra  Hospital  since  1880, 
analyzed  recently  by  Mr.  Marsh,*  there  were  35  deaths,  and 
17  of  these  were  caused  by  meningitis  or  phthisis.  From 
1867  to  1879  3.t  the  same  hospital  there  were  384  cases  of 
hip  disease,  and  only  23  deaths  from  tubercular  meningitis. 
All  these  cases  were  treated  conservatively. 

In  coming  to  the  consideration  of  operative  treatment, 
Konig  t  reports  that,  of  21  hip  excisions,  47.6  per  cent,  died 
of  tuberculosis  inside  of  four  years.  Wartmann  analyzed 
837  resections,  and  found  that  10  per  cent,  of  all  deaths  were 

*  Br.  Medical  Journal,  Aug.  3,  1889.  t  Arcliiv  f.  Klin.  Chir.,  xxvi.  822. 


126  DISEASE    OF    THE    HIP    JOINT 

the  result  of  rapidly  appearing  miliary  tuberculosis.  Mr. 
Barker,  in  a  lecture  before  the  Royal  College  of  Surgeons 
in  1888,  stated  that  in  10  per  cent,  of  all  deaths  follow- 
ing excision  "  rapid  miliary  tuberculosis  came  on  in  such  a 
way  as  to  suggest  strongly,  if  not  to  prove,  that  the  surgi- 
cal interference  was  the  cause  of  the  generalization  of  the 
disease." 

Caumont  treated  26  cases  of  hip  disease  by  conservative 
measures,  and  found  that  one-fifth  died  of  tubercular  disease  ; 
while,  of  22  cases  resected,  one-third  died  of  generalization 
of  the  tuberculosis. 

These  figures  seem  enough  to  establish  the  fact  that 
resection  of  the  hip  does  not  prevent  general  tubercular 
infection. 

ic)  Functional  Results. —  It  will  be  readily  understood  from 
the  casual  consideration  of  the  matter  that  the  results  after 
excision  are  not  likely  to  be  so  good  from  a  mechanical 
standpoint  as  when  a  cure  has  been  secured  by  other  means. 
It  is  not  as  if  it  were  possible  to  do  a  complete  subperiosteal 
operation  and  shell  out  the  bone,  leaving  its  case.  This, 
in  most  instances,  is  not  practicable.  On  the  contrary,  very 
important  muscular  insertions  are  severed,  the  joint  capsule 
is  destroyed,  the  head  of  the  femur  is  removed,  and  with  it, 
perhaps,  part  or  all  of  the  neck,  and  possibly  the  trochanter 
major,  and  even  part  of  the  shaft.  This  leaves  a  headless 
femur  in  loose  or  uncertain  contact  with  the  acetabulum. 
As  a  matter  of  fact,  the  results  are  not  so  bad  as  one 
would  expect ;  often  they  are  almost  perfect.  There  is,  of 
course,  alwas'S  shortening;  but  a  new  joint  may  form  of 
very  good  character,  and  be  movable  and  serviceable.  The 
dissection  of  such  a  case  is  figured  in  Sayre's  Orthopedic 
Surgery  as  the  frontispiece ;  and  other  cases  have  been 
reported  by  Kuster,   Israel,  and  many  others. 

In  the  case  of  Sayre  there  had  been  the  formation  of  a 
new  fibrous  capsule  and  of  new  cartilage,  and  of  course  in 
every  operation    an    attempt  should    be    made    to  save    the 


THE    TREATMENT    OF    HIP    DISEASE  12/ 

periosteum  as  much  as  possible ;  but  in  the  later  cases  the 
periosteum  is  either  so  hopelessly  diseased  or  so  nearly- 
wanting  that  it  has  not,  in  the  writer's  experience,  been 
possible  to  save  it  to  any  extent. 


Fig.  41. —  RESULT   OF   HIP   EXCISION    FOUR   YEARS    AFTER   OPERATION.      SINUSES    DISCHARGING. 

LIMB    PARTLY   USELESS   AND    POSITION    FAIR.      CHILD   CAN   WALK   WITH    CRUTCH. 

TO    BE   CLASSED    AS    A    FAIR    RESULT. 

Anchylosis  may  result  after  excision,  which  is  a  good  and 
desirable   result,  and,  perhaps,  safer  than   a   movable  joint 


128  DISEASES    OF    THE    HIP   JOINT 

would    be  ;    but   firm   anchylosis    is    not    common    after   hip 
excision. 

The  results  of  late  excision  are  not  so  good  as  the  results 
of  early  operation  ;  but,  on  the  whole,  they  are  satisfactory, 
as  a  rule.     Very  often  the  most  wonderful   improvement  will 


Fig.  42. —  RESULT   OF    HIP   EXCISION    DONE   AS    A    LIFE-SAVING    MEASURE   ONE   YEAR    PREVIOUS 
TO    THE   TIME    OF    THE    PHOTOGRAPH. 

follow  almost  immediately  upon  operation.     The  case  photo- 
graphed will  serve  as  an  example. 

This  boy  was  seen  in  a  most  deplorable  condition.     Me- 
chanical treatment  had  been  abandoned  by  the  parents  ;  and 


THE    TREATMENT    OF    HIP    DISEASE 


129 


he  was  emaciated  and  so  feeble  that  he  was  helpless,  while 
the  hip  was  apparently  rapidly  disintegrating,  and  the  whole 
thigh  very  much  swollen  and  discharging  profusely.  Exci- 
sion was  at  once  undertaken  by  the  writer,  but  had  to  be 
abandoned  before  throwing  the  head  of  the  bone  out  of  the 
socket  on  account  of  the  boy's  alarming  condition.  Three 
weeks  later  the  operation  was  completed,  and  the  boy's 
present  condition  at  the  end  of  nine  months  can  be  seen. 
The  head  of  the  femur  was  eroded  and  diseased  as  far  as  the 
shaft,  the  acetabulum  necrosed,  and  all  the  parts  about  infil- 
trated;  yet  such  a  result  as  this  has  been  in  the  writer's 
experience  not  at  all  exceptional. 


Fig.  43. —  A    BAH    RESIILT    AFTER   EX'CISION    OF   THE    HIP. 

But  there  are  many  bad  results  after  excision.  Some 
cases  do  well  for  a  while,  and  then  relapse.  Such  may  be 
counted  as  good  results.  Bradford  and  Lovett  report  a  case 
which  was  one  of  these.  This  case  was  reported  six  months 
after  excision,  in  Culbertson's  Tables,*  as  "  No.  464.  Re- 
covered in  six  and  two-thirds  months.  One-half  inch 
shortening.  Almost  perfect  motion."  Seen  five  years 
later,!  the    report  was   that   he  could  only  touch  the    floor 


*Trans.  Am.  Med.  Assoc,  1S76,  p.  142. 


■  N.V.  Med.  Journal,  April,  1.S79. 


130  DISEASES    OF    THE    HIP   JOINT 

with  the  toes  of  the  affected  Hmb,  on  which  he  could  bear 
little  or  no  weight ;  and  he  was  unable  to  walk  without  a 
crutch  or  cane.  This  case  may  serve  as  an  example  of  the 
later  histories  of  many  cases  of  excision  reported  as  suc- 
cesses. 

The  case  in  the  figure  may  serve  as  an  example  of  a  bad 
result  and  an  almost  useless  leg  following  excision.  The 
disease  was  originally  extensive  ;  but  some  years  after  opera- 
tion the  leg  was  as  shown  in  the  illustration,  with  the  sinuses 
still  discharging. 

With  regard  to  the  results  to  be  obtained  by  excision,  the 
lOO  cases  of  Mr.  Wright  are  instructive.  When  these  cases 
were  last  seen  by  Wright,  the  results  were  as  follows  :  — 

Soundly  healed, 17 

Unhealed,        - .  n 

Dead  or  dying, 18 

In  bad  condition, 3 

Amputated, 4 

Recent  case,  doing  well,        i 

100 

In  short,  about  20  per  cent,  might  be  classed  as  satisfac- 
tory at  that  time. 

Now,  30  of  these  cases  had  been  in  progress  only  nine 
months  or  less  when  excision  was  done,  being  the  most 
favorable  class  of  cases  possible  to  judge  of  the  value  of  the 
early  operation  ;  yet  one  is  surprised  to  find  that  4  died 
and  2  were  amputated,  6  healed  soundly,  7  were  unhealed 
at  the  end  of  one  year,  6  at  the  end  of  two  years,  while  5 
were  too  recent  for  classification.  The  Clinical  Society 
Committee  investigated  12  cured  cases  after  excision,  and 
found  that  2  could  stand  and  hop  on  the  excised  limb,  4 
could  stand  firmly,  4  others  could  stand,  but  not  firmly,  and  2 
could  not  stand  at  all ;  and  the  committee  reported,  as  a 
result  of  their  whole  investigation,  "  that  movement  is  more 
frequently  present,  and  is  also  more  extensive,  in  the  former 
class  (excision),  but  that  patients  often  walk  insecurely  and 


THE    TREATMENT    OF    HIP    DISEASE  I3I 

with  considerable  limp,  while  the  limb  after  treatment  by 
rest  and  extension,  though  frequently  more  or  less  fixed,  is 
more  firm  and  useful  for  purposes  of  progression."  * 

Elben  f  traced  6i  cases  of  hip  excision,  and  found  that  41 
■could  walk  without  apparatus,  15  required  some  apparatus, 
while  5  were  unable  to  walk  at  all.  J 

Grosch  §  states,  as  the  result  of  an  extensive  analysis  of 
cases,  that  the  functional  results  are  no  better  than  they 
were  before  the  day  of  antisepsis. 

Holmes  ||  speaks  of  the  end  results  of  excision  as  follows  : 
■"The  limb  is  hardly  ever  so  firm  or  powerful  in  walking  as 
we  constantly  see  that  it  is  after  the  natural  cure  by  anchy- 
losis, nor  is  the  patient  so  active  or  enduring." 

These  are  not  partisan  views,  but,  so  far  as  the  writer 
knows,  the  most  representative  expressions  of  opinion  on 
both  sides. 

Shortening  of  the  leg  must  necessarily  be  a  marked  feat- 
ure of  cases  treated  by  excision  of  the  joint,  not  only  on 
account  of  the  amount  of  bone  actually  removed,  but  also 
because  of  the  retarded  growth  due  to  the  removal  of  part 
of  the  epiphysis.  Mr.  Croft  believed  that  it  was  but  little 
greater  than  after  conservative  treatment.  The  average 
shortening,  however,  in  thirteen  of  his  cases,  reported  by 
him,  was  2f  inches.  In  Wright's  cases,  the  amount  of  short- 
ening is  only  given  in  thirty  cases,  where  it  was  li  inches. 

The  case  for  excision  is  not  a  strong  one,  as  must  be  evi- 
dent from  the  consideration  of  the  figures  given,  although 
no  one  is  more  aware  than  the  writer  of  the  unreliability  of 
statistics  in  general.  But  the  mortality  is  evidently  high. 
The  operation  does  not  prevent  systemic  infection.  The  pro- 
portion of  unhealed  and  unsatisfactory  cases  is  apparently 
larger  than  is  supposed  ;  and,  finally,  the  end  results  are  not 
satisfactory  altogether,  considering  them  by  themselves  and 

*  Trans.  Clin.  Society,  xiv.  p.  234.  t  Cent.  f.  Chir. ,  1882,  2,  77. 

t  Cent.  f.  Chir.,  1879,  No.  2.  §  Cent.  f.  Chir.,  1882,  xiv. 

II  Med.  Times  and  Gaz.,  Nov.  3,  1877. 


132  DISEASE    OF    THE    HIP    JOINT 

not  comparing  them  as  yet  with  the  results  of  conservative 
treatment. 

The  End  Results  of  Mechanical  Treatment. 

There  is  scarcely  more  value  to  be  attributed  to  the 
figures  relating  to  the  results  of  the  mechanical  treatment 
of  hip  disease  than  to  those  which  deal  with  excision.  They 
are  comparatively  few  in  number,  they  are  brought  forward 
by  partisan  writers,  and  they  deal  with  different  methods  of 
treatment.  Yet  they  offer  enough  information  to  make 
them  worth  careful  consideration. 

With  regard  to  the  worst  class  of  suppurative  cases, 
Cazin  had  charge  of  the  hospital  at  Berck  where  cases 
were  sent  from  the  hospitals  in  Paris  when  they  seemed 
hopeless  ;  and  these  cases  were  treated  by  mechanical  means 
in  an  atmosphere,  of  course,  very  favorable  to  improvement 
of  the  general  condition.  In  80  cases  of  such  hip  disease 
(all  suppurative)  treated  in  five  years  there,  i2\  per  cent, 
died,  55  per  cent,  were  cured,  72  per  cent,  were  improved, 
25   per  cent,   were   not  cured   or  improved. 

C.  Fayette  Taylor,  of  New  York,  reported  94  cases  of  hip 
disease  treated  by  the  long  traction  splint  under  favorable 
conditions,  with  91  recoveries  and  3  deaths.  24  of  these 
cases  were  suppurating  ones. 

Of  288  cases  which  Gibney  collected,  which  were  treated 
at  an  institution  where  the  treatment  was  purely  expectant, 
the  mortality  rate  was  only  12^  per  cent.;  and  these  figures 
are  of  interest  in  contrasting  what  is  practically  untreated 
hip  disease  with  the  results  of  excision. 

But  any  mortality  per  cent,  obtained  from  the  analysis  of 
recent  cases  must  evidently  be  of  little  value,  as  the  whole 
mortality  of  the  disease  must  include  man}^  late  cases,  where 
death  occurs  after  a  lapse  of  years.  It  must  on  this  ground 
be  evident  that  most  analyses  are  not  of  great  value,  inas- 
much as  they  have  to  do  with  cases  which  remain  under 
observation  only  a  short  time. 


THE    TREATMENT    OF    HIP    DISEASE  1 33 

Motion. —  With  regard  to  the  functional  results  to  be 
obtained,  the  information  is  more  definite.  Shaffer  and 
Lovett*  analyzed  51  cases  of  cured  hip  disease  discharged 
from  the  New  York  Orthopedic  Dispensary  from  four  to  ten 
years  previously.  4  of  these  had  died,  6  had  relapsed  ;  but 
41  were  well,  and  were  apparently  permanently  cured. 
These  latter  were  all  active  working  people  or  school  chil- 
dren. They  all  walked  without  cane  or  crutch  (with  one  ex- 
ception, where  Pott's  disease  was  also  present),  and  all  were 
free  from  any  serious  inconvenience  from  their  hip  disease. 
These  51  cases  were  the  only  ones  which  could  be  found  in 
some  75  cases  selected  for  investigation.  Those  selected 
cases  were  merely  all  those  living  in  or  near  New  York,  who 
had  been  discharged  as  cured  (after  being  at  least  two  years 
under  treatment)  between  two  dates. 

Few  parents  are  willing  to  persist  in  treatment  until  the 
children  can  be  considered  by  the  surgeon  as  cured,  and 
take  them  from  under  treatment  as  soon  as  the  patient  is 
convalescent ;  and  these  cases,  if  investigated,  would  proba- 
bly show  nearly  as  good  results  as  those  investigated  by 
Shaffer  and  Lovett.  Of  these  51  cases,  however,  there 
were  26  suppurative  cases  carefully  examined ;  and  they 
showed  as  good  an  average  of  joint  motion  as  cases  without 
abscess. 

There  were  2  recoveries  among  these  with  perfect  mo- 
tion in  every  direction,  3  with  90  degrees  of  motion,  5  with 
10  to  45  degrees  of  motion,  4  with  slight  motion,  and  12  with 
anchylosis.  These  cases  were  all  treated  by  ambulatory 
traction  throughout  the  disease. 

Howard  Marsh  analyzed  a  similar  class  of  hip  cases  one 
year  after  discharge ;  and  of  37  suppurative  cases  he 
found  perfect  joint  movement  in  i  case,  free  joint  move- 
ment in  10  cases,  slight  joint  movement  in  7  cases,  anchy- 
losis in  18  cases. 

Among  the  39  non-suppurative  cases  he  found  still  better 

*  N.Y.  Med.  Journal,  May  21,  1887. 


134  DISEASES    OF    THE    HIP    JOINT 

results  :  9  were  classed  as  perfect  recoveries,  9  were  classed 
as  excellent  recoveries,  12  were  classed  as  good  recoveries, 
9  were  classed  as  moderate  recoveries. 

These  cases  were  treated  by  traction  in  bed  and  fixation 
in  the  quiescent  stages  of  the  disease. 

Shortening  is  less  important  than  motion  ;  but  the  results 
of  mechanical  treatment  are  excellent  in  this  respect.  In 
the  cases  of  Shaffer  and  Lovett  the  shortening  was  from 
half  an  inch  to  two  and  a  half  inches,  with  2  exceptions.  2 
cases,  on  the  other  hand,  had  no  shortening.  Suppurative 
cases  had  a  little  more  shortening  than  the  others,  but  the 
table  shows  how  slight  is  the  difference  : — - 

Shortening.  Supp.  cases.  Non-supp.  cases. 

None  2 

^  inch  I  I 

1  inch  5  5 
i^  inches  4  3 

2  «  8  I 
2i       "                                            5 

3"      "  I 

6       "  I 

Of  Marsh's  2)7  suppurating  cases,  3  had  no  shortening, 
17  had  less  than  one  inch,  12  had  from  one  to  two  inches, 
3  had  two  inches  or  more,  while  the  average  of  non-suppu- 
rating cases  was  two-thirds  of  an  inch. 

The  Results  of  Expectancy. 

Even  expectancy  or  no  treatment  at  all  is  not  attended 
by  such  bad  results  as  one  would  expect.  Gibney*  inves- 
tigated 80  cases  of  hip  disease  from  the  Hospital  for  the 
Ruptured  and  Crippled,  and  found  that  61  could  walk  well, 
while  12  had  an  arc  of  motion  of  15  degrees  or  more.  This 
is  not  intended  to  excuse  such  lack  of  treatment,  but  to 
show  that  the  disease  cannot  certainly  be  considered  so  ma- 
lignant as  some  English  surgeons  would  have  us  believe. 

*N.Y.  Med.  Record,  March  2,  1878. 


THE    TREATMENT    OF    HIP    DISEASE  1 35 

Excision  v.  Mechanical  Treatment. 

The  outcome  of  all  this  is  the  question  as  to  which  of 
these  methods  offers  the  best  prospect  in  hip  disease,  a 
conclusion  which  the  writer  has  endeavored  to  present  only- 
after  a  careful  and  separate  consideration  of  the  results  to 
be  expected  from  each  method  of  treatment.  Two  questions 
proposed  at  the  beginning  of  the  section  on  excision  can 
now  be  fairly  answered  on  the  evidence  presented. 

One  was,  Does  operation  diminish  the  mortality  of  hip 
disease  .?  The  answer  is  plainly,  No.  The  other  question 
was,  Are  the  results  better  after  operative  than  after  mechan- 
ical treatment }  And,  again,  the  answer,  as  established  by 
the  evidence  presented,  would  be.  No. 

Those  surgeons  who  believe  that  early  excision  is  the  best 
treatment  for  hip  disease  (of  whom  the  most  prominent  rep- 
resentatives are  Mr.  Barker,  of  London,  and  Mr.  Wright,  of 
Manchester)  are  inclined  to  advocate  very  radical  views  in 
this  direction.  It  is  difficult  for  American  surgeons  to 
appreciate  the  grounds  on  which  Mr.  Barker  *  advocates 
excision  of  the  hip  joint  as  "  soon  as  it  is  suspected  that 
caseation  is  advancing  in  it,"  until  it  is  understood  that 
Mr.  Barker  regards  "  tubercle  in  the  light  of  a  malignant 
growth,"  and  would  deal  with  it  accordingly.  Of  course,  if 
this  view  is  accepted,  the  position  of  these  extremists  is  not 
to  be  criticised.  "  It  is  impossible,  however,  to  shut  one's 
eyes  to  the  fact  that  this  is  an  estimate  of  tuberculosis 
which  the  great  majority  of  surgeons  would  not  for  a  min- 
ute entertain.  The  estimate  formed  by  Brodie,  indorsed  by 
Paget  and  Hilton,  and  accepted  by  a  very  large  proportion 
of  those  who  have  studied  the  subject  from  a  clinical  point 
of  view,  is  that,  though  often  intractable  and  destructive  in 
its  later  stages,  tuberculosis,  on  a  general  survey,  wears  the 
aspect    of    merely   an    obstinate   inflammatory    process,   the 

*  Brit.  Med.  Journal,  June  9, 1888. 


136  DISEASES    OF    THE    HIP    JOINT 

whole  course  and  progress  of  which  are  widely  divergent 
from  those  of  malignant  disease." 

This  quotation  from  Mr.  Howard  Marsh  *  is  a  fair  state- 
ment of  the  position  in  the  matter  as  it  appears  to  most 
surgeons.  The  justification  of  early  excision  of  the  hip 
cannot  be  found  on  these  grounds,  evidently.  It  must  rest 
on  diminished  mortality  or  improved  results,  and  these  as- 
pects of  the   question  have  just  been   considered. 

Yet,  from  his  experience  with  excision  of  the  hip,  Wright 
has  reached  no  more  temperate  conclusion  than  that  "  treat- 
ment short  of  excision,  where  once  suppuration  occurs,  is 
useful  only  as   a  palliative  or  means  of  temporizing." 

Now,  these  statements  of  Mr.  Wright  and  Mr.  Barker  are 
much  more  radical  than  those  of  the  Clinical  Society's  Com- 
mittee, who  reported  in  1880,  among  their  conclusions,  that 
"  with  respect  to  the  general  question  of  operative  interfer- 
ence [in  hip  disease]  the  committee  are  of  opinion  that  the 
effect  of  complete  rest  and  weight,  or  other  modes  of  ex- 
tension, with  the  withdrawal  of  matter,  should  always  be 
patiently  tried  in  the  first  instance,  and  that  operative  in- 
terference should  be  resorted  to  only  .when  these  means 
have  failed  to  secure  the  favorable  progress  of  the  case." 
Certainly,  Mr.  Wright's  figures  in  no  wise  justify  the  position 
which  he  takes,  as  must  have  been  especially  seen  when  the 
consideration  of  the  end  results  of  mechanical  treatment 
was  taken  up. 

It  seems  unnecessary  to  dwell  longer  on  the  fact  that  exci- 
sion of  the  hip  cannot  be  accepted  as  the  proper  treatment  of 
hip  disease. 

The  writer  can  only  state  his  views,  which  he  believes  to 
be  representative  of  those  of  most  American  orthopedic 
surgeons.  Excision  of  the  hip  is  to  be  considered  a  proper 
and  necessary  measure  under  two  circumstances, —  where 
mechanical  treatment  is  not  obtainable,  and  where  mechan- 
ical treatment,  after  careful  and  intelligent  trial,  has  failed. 

*  Brit.  Med.  Jounial,  July  20,  iSSg,  p.  121. 


THE    TREATMENT    OF    HIP    DISEASE  1 3/ 

The  children  of  the  lower  classes,  in  cities  where  hospital 
facilities  are  poor  and  where  the  parents  are  so  circumstanced 
that  they  could  not  carry  out  simple  bed  traction,  are  to  be 
considered  fit  subjects  for  excision,  if  it  seems  clear  that  the 
better  treatment  cannot  be  put  within  their  reach.  Where 
proper  mechanical  facilities  are  to  be  obtained,  it  would  be 
the  writer's  feeling  that  excision  should  not  be  undertaken. 
Fortunately,  this  class  of  cases,  where  conservative  treat- 
ment is  not  obtainable,  is  steadily  growing  smaller  with  the 
increase  of  hospital  advantages. 

With  regard  to  the  time  when  mechanical  treatment 
should  be  abandoned  in  favor  of  operation  the  question  is 
a  more  difficult  one  to  decide ;  nor  is  it  possible  to  lay  down 
any  definite  rule  which  can  be  followed.  The  question  in 
every  case  is  one  which  should  be  settled  by  a  delicate  bal- 
ancing of  the  different  features  of  the  case. 

In  suppurating  cases,  where  there  is  a  porky  induration  of 
the  thigh  and  a  profuse  discharge  from  numerous  sinuses, 
any  pronounced  failure  of  the  general  condition  should  lead 
the  surgeon  to  consider  the  advisability  of  excision.  Other 
cases  show  plainly  that  a  rapid  disintegration  of  bone  and 
soft  parts  is  taking  place,  and  this  goes  on  steadily  in  its  de- 
structive course  in  spite  of  mechanical  measures  until  it 
becomes  evident  that  a  limit  must  be  set  to  the  process. 
This  is  not  common  in  cases  under  control,  but  in  excep- 
tionally tuberculous  children  it  occurs.  Again,  excision  may 
be  necessary,  in  exceptional  cases,  where  excruciating  pain  is 
suffered,  which  cannot  be  relieved  by  mechanical  treatment. 
In  many  cases,  simple  incision  of  the  joint  will  relieve  it; 
while,  again,  excision  may  be  necessary  as  a  further  measure. 

Such  rules  as  were  laid  down  for  excision  by  the  Com- 
mittee of  the  Clinical  Society  are  not  of  use  to-day,  because 
the  methods  of  treatment  have  been  changed  and  improved  ; 
and  the  presence  of  necrosis  or  pelvic  disease  is  in  no  way  to 
be  considered  an  indication  for  excision. 

Any  extended  discussion  of  the  technique  of  the  operation 


138 


DISEASES    OF    THE    HIP    fOIXT 


of  excision  of  the  hip  does  not,  in  the  writer's  opinion,  come 
within  the  scope  of  this  essay. 

The  posterior  incision  is  the  one  ordinarily  used.  The 
head  of  the  bone  should  be  thrown  from  the  socket  before 
being  sawed  off,  and  is  thrown  out  most  easily  posteriorly. 
It  is  not  generally  possible  to  remove  all  diseased  tissue 
from  the  acetabulum.  The  photographs  of  the  various 
stages  of  the  operation  may  serve  better  than  a  description 
to  make  the  matter  plain. 


Fig.  44. —  POSITION    OF    THE    PATIENT    FOR    EXCISION   OF    THE    HIP   JOINT. 

After  excision  the  hip  should  be  protected  for  a  long  time, 
preferably  by  some  splint  combining  fixation  and  traction. 
Excision  cannot  be  considered  as  a  means  of  cutting  short 
the  disease,  because  a  hip  joint  after  excision  demands  very 


THE    TREATMENT    OF    HIP    DISEASE 


139 


Fig.  45. —  THE  INCISION    EXPOSING    THE   TROCHANTER    AND    NECK    OF   THE    FEMUR. 


Fig.  46. —  THE   HEAD   OF   THE   FEMUR   THROWN    OUT   OF   THE   SOCKET    PREPARATORY    TO   CUT- 


I40 


DISEASES    OF    THE    HIP    lOlXT 


Fig.   47. —  THE    HEAD    OF    THE    FE.MIR    REMOVED    AND    THE    I.Ei;    AI.AIN    IN     ILACE. 


Fig.  4.S. —  THE    DRESSING    AriLIED.      THE  SPLINT    IN    THIS   CASE    IS    THE    CACOT     POSTERIOR 

WIRE   FRAME. 


THE    TREATMENT    OF    HIP    DISEASE  I4I 

careful    protection,  at   least    from  weight-bearing,  for  many 
months. 

In  short,  excision  should  be  kept  as  a  last  resort,  to  be 
undertaken  only  when  mechanical  treatment  is  not  to  be 
had,  or  having  been  tried  faithfully  and  skilfully  has  failed. 


Incision  of  the  Hip  Joint. 

This  measure  is  of  use  in  persistently  painful  cases,  where 
salicylate  of  soda  and  traction  fail  to  relieve  the  pain,  and  in 
cases  of  persistent  abduction,  where  there  is  slight  fulness 
beneath  the  adductor  tendons,  this  condition  being  gener- 
ally associated  with  distention  of  the  joint.  Two  cases  were 
reported  by  Dr.  Bradford,  where  much  relief  was  afforded.* 

The  incision  may  be  made  either  anteriorly,  in  the  line  of 
the  anterior  superior  spine,  as  described  by  Mr,  Barker,  or 
posteriorly,  as  for  an  excision  of  the  joint.  The  incision  is 
likely  to  persist  as  a  sinus  ;  but,  as  it  is  made  for  drainage 
purposes,  this  cannot  be  considered  an  objection. 


Trephining  of  the  Head  of  the  Femur. 

This  operation  was  advocated  by  Fitzpatrick  twenty-five 
years  ago ;  and  recently  Stoker  f  has  written  in  favor  of  it, 
and  has  advocated  it  as  routine  treatment,  which  seems  un- 
reasonable. At  times  it  may  be  a  useful  measure,  as  afford- 
ing bone  drainage  ;  but,  in  general,  it  has  little  place  in  the 
treatment  of  hip  disease.  One  or  two  cases  only  have  been 
reported  in  America.  It  might  be  tried  in  cases  where 
incision  failed  to  relieve  an  acutely  painful  condition,  and 
where  it  was  not  desired  to  excise  the  joint.  The  trochanter 
major  is  exposed,  and  a  trephine,  or  gouge,  is  driven  through 
the  neck   well  into   the  head  of    the  femur.     The  plan   of 

*Bost.  Med.  and  Surg.  Journal,  Aug.  16,  1888.  t  Dublin  Journal, 1B86,  S.  3,  p.  81. 


142  DISEASES    OF    THE    HIP    JOINT 

Fitzpatrick  was  to  insert  caustic  potash  into  the  hole  ;  but  a 
curette  will  remove  all  the  tissue  necessary,  and  the  trephine 
hole  should  be  kept  open  as  a  drain. 

IgnipiDicture,  as  a  mode  of  treatment,  deserves  mention 
onlv  to  make  the  account  complete.  Kolominn  *  is  the  ad- 
vocate of  the  measure,  and  claims  wonderful  results  in  hip 
disease  from  both  deep  and  superficial  cauterizations  with 
the  Pacquelin  point.  The  writer  has  had  no  experience 
with  it,  and  has  seen  no  reports  of  cases. 

Amputation  at  the  Hip  Joint. 

The  question  of  amputation  only  arises  in  the  case  of 
adults  and  in  patients  who  are  beyond  the  reach  of  excision, 
or  who  continue  to  do  badly  even  after  the  joint  has  been 
excised.  It  is  not  a  measure  to  be  lightly  advocated;  but, 
on  the  other  hand,  it  is  capable  of  producing  a  marvellous 
change  in  the  general  condition,  in  certain  cases,  where 
there  is  extensive  pelvic  disease,  and  excision  has  been 
done,  leaving  a  diseased  femur.  The  combined  irritation  of 
the  two  is  enough  to  cause  serious  local  disturbance ;  and 
the  removal  of  the  femur  and  the  free  drainage  to  the  pelvic 
disease,  only  attainable  by  amputation,  may  be  sufficient  to 
cause  a  cessation  of  the  local  disturbance,  to  the  great  im- 
provement of  the  general  condition. 

The  mortality  of  this  amputation,  as  done  for  hip  disease, 
is  not  so  high  as  one  would  expect  it  to  be. 

The  death-rate  of  hip  amputation  for  injury,  according  to 
Ashhurst's  tables,!  is  70.9  per  cent.,  and  for  disease  in 
general  42.6  per  cent.  But  for  hip  disease  alone  60  cases 
gave  a  mortality  of  only  32  per  cent.  Of  22  cases  in  a  col- 
lection not  given  by  Ashhurst  there  were  only  3  deaths, 
making  ^2  cases  with  22  deaths  (27  per  cent.).  And  in  the 
22  cases  collected  since   1880  there  were  only  3  deaths  (14 

•  Bost.  Med.  and  Surg.  Journal,  Apri'  26,  1SS5,  Orth.  Report,  392. 
+  Int.  Encyc.  of  Surg.,  vol.  iv,  p.  501. 


THE    TREATMENT    OF    HIP    DISEASE  I43 

per  cent.),  all  of  which  shows  that  amputation  of  the  hip,  as 
done  for  hip  disease,  is  an  operation  much  less  formidable, 
as  done  by  modern  methods,  and  especially  as  done  for  the 
relief  of  hip  disease.  It  should,  however,  be  borne  in  mind 
that  such  statistics  as  these  are  undoubtedly  too  favorable, 
because  the  tendency  is  to  report  successes,  and  not  to 
report  failures.  So  that,  in, almost  any  operation  where  the 
cases  are  reported  only  in  small  groups,  as  here,  the  ten- 
dency is  to  present  too  favorable  an  aspect,  unless  one  bears 
this  fact  in  mind. 

Unless  the  femur  is  very  extensively  diseased,  or  unless 
the  amount  of  pelvic  disease  is  exceptionally  large,  it  is 
proper  to  excise  the  joint  rather  than  amputate  the  leg  in 
the  case  of  children.  But  here,  again,  it  is  not  possible  to 
lay  down  rules,  and  each  case  must  be  decided  by  its  individ- 
ual features. 

When  excision  has  been  performed  and  has  failed  to  pro- 
duce much  effect,  and  the  vital  powers  are  notably  failing, 
it  seems,  to  the  writer,  proper  to  present  to  the  parents  the 
question  of  amputation  as  a  life-saving  measure.  And  his 
personal  experience  with  the  operation  would  lead  him  to 
advise  it,  but  by  no  means  to  urge  it. 

In  many  cases,  it  is  possible  to  fit  an  artificial  limb  to 
the  stump ;  and,  in  a  case  reported  by  Dr.  Bradford,*  re-for- 
mation of  bone  occurred  in  the  stump.  This  is,  of  course, 
unusual  in  the  extreme. 

In  adults  the  operation  is  more  often  indicated  than  in 
children.  Wright  would  not  excise  in  patients  over  fif- 
teen, Jacobson  would  set  the  limit  at  eighteen  for  excision, 
and  nearly  all  surgeons  are  in  accord  that,  in  view  of  the 
severity  of  tuberculous  ostitis  of  the  hip  in  the  adult,  the 
more  radical  measure  is  to  be  adopted,  if  any  operative  pro- 
cedure is  undertaken.  And  the  indication  for  the  operation 
would  again  be  the  failure  of  mechanical  treatment  after 
a  faithful  trial. 

*  Bost.  Med.  and  Surg.  Journal,  Sept.  13,  1885. 


144  DISEASES    OF    THE    HIP    JOINT 

There  is  no  need  of  entering  upon  the  technique  of 
amputation  of  the  hip.  A  great  gain  has  been  made  by 
the  adoption  of  Furneaux  Jordan's  method,  which  consists 
briefly  in  amputation  of  the  thigh  at  the  upper  third,  with 
removal  of  the  head  and  shaft  of  the  femur  by  a  lateral  in- 
cision. The  periosteum  should  be  carefully  preserved,  in 
order  to  favor  the  formation  of  new  bone,  as  in  Bradford's 
case.  This  method  saves  blood,  diminishes  shock,  and  gives 
a  better  stump  than  any  flap  method  possibly  can.  The 
method  is  dwelt  upon  at  length  in  all  modern  surgical  text- 
books. The  operation  must  be  done  rapidly,  and  with  every 
precaution  against  hemorrhage  and  shock. 


GUMMATOUS    OSTITIS    OF    THE    HIP  I45 


Chapter  VII. 

GUMMATOUS    OSTITIS   OF   THE   HIP. 

Pathology. 

Gummatous  formations  about  the  hip  joint  are  most  often 
to  be  found  in  the  synovial  membrane  or  in  the  ligaments 
and  periarticular  structures.  These  conditions  have  been 
discussed  in  speaking  of  chronic  synovitis. 

Especially,  however,  are  they  to  be  found  in  the  perios- 
teum, where  they  are  attended  by  much  thickening  and 
succulency  of  the  covering  of  the  bone,  while  at  times  they 
appear  simultaneously  in  the  bone,  the  joint,  and  the  periar- 
ticular structures.  When  synovitis  exists  in  connection 
with  the  formation  of  gummata,  most  often  it  is  the  primary 
affection,  although  the  synovial  inflammation  may  be  sec- 
ondary to  the  osseous   trouble. 

Gummata  of  the  spongy  tissue  rarely  occur  in  the  epi- 
physes of  the  long  bones  ;  but  some  recent  researches  of 
Chiari  *  would  seem  to  show  that  they  are  not  so  very 
uncommon  as  had  been  supposed. 

When  they  are  present,  they  are  to  be  identified  as  yellow- 
ish or  grayish  nodules,  in  appearance  somewhat  like  foci  of 
tuberculosis  except  that  they  are  not  surrounded  by  a  zone 
of  hypersemia.  Sometimes  they  are  purulent  in  appearance, 
and  sometimes  cheesy. 

Within  the  nodule  the  bone  is  necrotic  and  disintegrated, 
and  in  part  broken  down  into  pus,  and  in  part  replaced  by  a 
typical  gummatous  formation.  Such  gummata,  rare  as  they 
are,  almost  always  exist  along  with  a  neighboring  periostitis 
and  overgrowth  of  bone  in  the  neighborhood, 

*  Vierteljahrsch.  f.  Derm,  und  Syph.,  1882. 


146  DISEASES    OF    THE    HIP   JOINT 

Probably  the  commonest  condition  is  an  osteochondritis, 
which  is  accompanied  by  a  periostitis  and  perichondritis  of  a 
gummatous  type,  all  occurring  in  the  neighborhood  of  the 
epiphysis  of  the  head  of  the  femur.*  There  is  much  en- 
largement of  the  bone  in  that  region  ;  and  the  periosteum  is 
thickened  and  of  an  elastic  consistency,  and  on  microscopic 
examination  it  is  seen  to  be  rich  in  fluid  and  poor  in  cellular 
elements.  This  condition  may  result  in  a  purulent  degener- 
ation, or  in  caseation,  or  in  the  formation  of  fibrous  tissue 
leading  to  a  scar  formation.  Under  the  place  where  the 
gummata  are  found,  the  bone  is  absorbed,  and  the  amount 
of  absorption  is  great  in  proportion  to  the  size  and  cellular 
activity  of  the  gummata.  With  this  is  associated  a  tendency 
to  the  formation  of  hyperostoses  in  the  neighborhood. 

If  this  osteochondritis  becomes  purulent  and  destructive, 
the  epiphysis  of  the  femur  may  be  loosened,  or  more  com- 
monly a  purulent  synovitis  is  started  up.f 

Etiology. 

As  elsewhere  in  the  body,  the  occurrence  of  gummata  in 
the  hip  joint  is  to  be  attributed  to  the  presence  of  late 
syphilis,  either  acquired  or  hereditary. 

Syphilitic  osteochondritis  occurs  most  often  in  young 
children  who  have  inherited  syphilis.  The  other  manifes- 
tations, rare  clinically,  are  to  be  met  in  either  the  inherited 
or  the  acquired  form. 

Treatment. 

The  treatment  of  gummatous  inflammation  of  the  hip  is, 
of  course,  first,  the  administration  of  iodide  of  potash  and 
the  inunction  locally  of    mercurial  ointment,  together  with 

*  Deutsch.  Arch.  f.  Chir.,  xxviii.  2  ;  Archiv  f.  Kinderheilkunde,  1SS4,  5  (Cassell). 

t  Syphilis  of  Joints :  Lanceraux,  Traite  Hist,  et  Prat,  de  la  Syphilis,  1874 ;  Baumler,  Ziemssen's 
Handbuch,  iii.,  iS86;  Deutsch.  Arch.  f.  Klin.  Med.,  ix.,  1S70 ;  Duffin,  Trans.  Clin.  Soc,  London, 
ii.,  1869;  Oedmanson,  Nordisk.  Med.  Arck.,  i.,  1S69;  Gies,  D.  Zeitsch.  f.  Chir.,  xv. ;  Finger, 
Wien.  Med.  Wchsft.,  1884;  Saug,  Vorles.  iiber  Path.  u.  Thar.  d.  Syph.,  Wiesbaden,  1885. 


GUMMATOUS    OSTITIS    OF    THE    HIP  I47 

the  exhibition  of  tonics  and  the  adoption  of  hygienic  meas- 
ures. Secondly,  local  measures  are  to  be  adopted  to  fix  the 
joint  and  prevent  irritation  from  traumatism,  which  can 
easily  be  accomplished  by  the  fixation  splints  already  de- 
scribed. 

If  the  diagnosis  between  tuberculosis  and  syphilis  of  the 
hip  joint  is  not  clear  (and  this  must  often  happen  in  the 
present  state  of  knowledge),  the  existence  of  the  more  de- 
structive disease  must  be  assumed,  and  the  child  subjected  to 
the  mechanical  measures  described  for  hip  disease,  as  well 
as  to  the  constitutional  treatment  just  mentioned. 


148  DISEASES    OF    THE    HIP    JOINT 


Chapter  VIII. 
ARTHRITIS    DEFORMANS    OF    THE    HIP   JOINT. 

Arthritis  deformans  of  the  hip  joint,  or  malum  coxce  senile, 
is  considered  by  itself  instead  of  in  connection  with  the 
sections  on  synovitis  or  ostitis,  because  it  is  an  affection 
whose  origin  is  variously  attributed  to  the  three  different 
tissues  composing  the  joint,  by  the  different  authorities.  It 
seems  also  a  justifiable  division,  because  the  affection  is  so 
well  marked  as  to  appear  as  a  pathological  entity. 

The  origin  of  ostitis  deformans  has  been  ascribed  to  the 
synovial  membrane  by  Volkmann,  Brodie,  Adams,  and  others  ; 
to  the  cartilage  by  Cornil  and  Ranvier,  Howard  Marsh,  Orth, 
Garrod,  and  Billroth  ;  and  to  the  bone  by  Barwell,  and  some 
less  reliable  authorities.  With  such  a  wide  difference  of 
opinion  among  the  authorities,  it  seems  wisest  to  consider 
the  origin  of  the  affection  unsettled. 

The  affection  is  also  spoken  of  as  rheumatic  or  rheumatoid 
arthritis  (Adams  and  Garrod) ;  rheumatic  gout ;  osteoarthritis 
(Royal  College  of  Physicians)  ;  nodular  rheumatism,  rJieiima- 
tisme  noueiix  (Trousseau)  ;  nodosity  of  the  joints  (Haygarth)  ; 
chronic  rheumatism  of  the  joints  (Todd  i') ;  goutte  asthe- 
niqne  primitive  (Landre  Beauvais)  ;  senile  arthritis  ;  arthri- 
tis urica ;  malum  senile  ;  rheumatisme  chr.  primitif  (Char- 
cot) ;  arthritis  chronica  ulcerosa  sicca. 

Although  it  may  be  questionable  whether  all  these  names 
should  be  admitted  to  be  synonymous  with  arthritis  de- 
formans (Virchow),  the  pathological  distinctions  between 
them  are  so  slight  that  it  seems  simplest,  and  therefore 
best,  to  consider  them  all  practically  as  modification  of  one 
process. 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  I49 


Pathology. 

The  characteristics  of  the  affection  are  chiefly  to  be  found 
in  the  disintegration  and  erosion  of  the  articular  cartilages, 
along  with  a  tendency  to  increased  bony  formation  about  the 
margin  of  the  head  of  the  femur. 

It  has  been  a  matter  of  discussion  whether  the  changes  to 
be  described  were  inflammatory  or  not ;  and  the  modern 
conclusion  is  expressed  by  Senator,  who  says,  "The  changes 
in  the  joints  are  partly  inflammatory,  partly  degenerative."  * 

The  changes  are  perhaps  earlier  noted  in  the  cartilage 
than  they  are  elsewhere ;  and,  since  cartilage  has  but  one 
way  of  reacting  to  inflammation  and  but  one  form  of  degen- 
eration, it  is  found  in  arthritis  deformans  to  follow  that  type. 
The  cells  multiply,  and  the  hyaline  substance  undergoes 
fibrillary  degeneration.  This  renders  the  cartilage  more 
friable  than  it  should  be  ;  and  it  looks  yellowish  and  shreddy, 
and  shows  a  tendency  to  wear  away  where  the  two  articular 
surfaces  are  in  contact.  To  the  naked  eye  it  presents  the 
appearance  of  velvet.  In  other  places  it  perhaps  is  split  off 
in  pieces  of  considerable  size.  In  connection  with  this  dis- 
integration, there  is  an  hypertrophy  of  the  cartilage  around 
the  periphery.  Marginal  ecchondroses  develop,  which  may 
reach  such  a  size  that  they  perforate  the  synovial  membrane, 
and  appear  in  the  joint  as  pedunculated  or  even  as  loose 
bodies. 

The  ecchondroses  are  most  marked  at  the  margins,  prob- 
ably because  the  cartilage  is  in  that  situation  covered  by  a 
layer  of  synovial  membrane,  which  prevents  the  escape  of 
the  proliferating  and  multiplying  cartilage  cells. 

Where  ossification  of  these  ecchondroses  begins,  it  is  in 
the  layers  nearest  the  bone  ;  and,  even  when  ossification  is 
well  advanced,  they  are  still  covered  by  a  layer  of  cartilage 
on  their  joint  surface. 

*Ziemssen's  Hdbch.,  1875,  art.  Arth.  Deformans. 


150  DISEASES    OF    THE    HIP    JOINT 


Bony  Changes. 

The  disintegration  of  the  cartilage  brings  together  two 
bony  surfaces  unprotected  by  articular  cartilage.  But  nature 
has  already  provided  for  this  contingency  by  certain  changes 
which  have  taken  place  in  the  bone  before  the  cartilage  was 
entirely  destroyed.  The  condensation  in  the  ends  of  the 
bones  where  they  are  in  contact  is  the  striking  feature. 
The  bony  surface,  as  exposed  by  the  loss  of  the  cartilage, 
is  dense  and  white,  and  capable  of  withstanding  pressure. 
It  resembles  nothing  so  much  as  ivory ;  and,  if  motion 
exists  in  the  affected  hip,  it  is  capable  of  acquiring  a  remark- 
able polish,  equal  to  that  of  the  finest  ivory.  But,  with  the 
rubbing  together  of  two  such  surfaces,  wearing  away  of  the 
bone  must  ensue  ;  and  exposure  of  the  ends  of  Haversian 
canals,  and  perhaps  of  cystic  cavities  results,  which  causes 
a  worm-eaten  appearance,  which  the  head  of  the  femur  often 
presents. 

The  formation  of  this  eburnated  bone  is  variously  ac- 
counted for.  Ziegler  believes  that  it  is  the  result  of  a 
softening  process  which  has  occurred  in  the  deeper  layers 
of  the  cartilage.  This  has  resulted  in  cavities,  which  have 
been  filled  by  a  vascular  marrow  which  has  grown  into  them 
from  the  changed  and  degenerated  bone  marrow,  which  loses 
much  of  its  fat  and  becomes  in  a  measure  a  "lymphoid 
marrow,"  or  it  may  become  fluid  and  sometimes  be  included 
as  cysts,  which  may  afterward  be  exposed  as  the  bone  is 
worn  down.  This  growth  of  the  bone  marrow  into  the  car- 
tilage favors  its  early  ossification. 

Other  writers  attribute  the  formation  of  the  eburnated 
bone  to  a  local  ostitis,  and  others  attribute  it  to  purely  me- 
chanical influences.  However  it  comes  about,  a  thin  layer 
of  very  dense  bone  is  formed  at  the  articular  end  of  the 
femur. 

Apart  from   this   formation    of    eburnated   bone   and    the 


ARTHRITIS    DEFORMANS    OF    THE    HIP   JOINT  151 

ossification  of  the  hypertrophies  which  have  occurred  around 
the  periphery  of  the  articular  cartilage,  the  process  may  be 
chiefly  one  of  bone  atrophy  or  absorption,  or  one  of  bone 
overgrowth. 

In  the  one  case,  the  cancellous  tissue  of  the  epiphysis  is 
thinned  and  eroded,  and  the  cancellous  interstices  occupied 
with  fat;  or,  in  the  other,  it  is  abnormally  thickened  and 
dense,  not  only  in  the  epiphysis,  but,  in  some  cases,  in  the 
shaft  as  well. 

From  the  fact  that  the  cartilage  and  bone  are  worn  away 
by  pressure  where  the  articular  surfaces  are  in  contact,  and 
that  the  activity  of  cartilage  hypertrophy  and  bone  forma- 
tion is  chiefly  around  the  periphery  of  the  head  of  the  femur, 
it  follows  that  the  head  of  the  femur  becomes  less  globular 
and  decidedly  flattened.  In  bad  cases,  the  head  of  the  femur 
may  almost  entirely  disappear,  leaving  an  irregular,  stunted, 
and  useless  mass  of  bone  where  the  globular  head  formerly 
was.  This  change  is  spoken  of  as  "absorption  "  of  the  head 
of  the  femur. 

A  word  more  should  be  said  about  absorption,  so  called, 
of  the  head  or  neck  of  the  femur,  where  the  neck  is  short- 
ened and  at  a  right  angle  to  the  shaft.  The  head  wears 
away,  and  the  marginal  exostoses  carry  the  rounded  joint 
surface  apparently  toward  the  trochanter.  As  the  head  is 
worn  away  more  and  more,  the  marginal  overgrowth  pro- 
gresses toward  the  trochanter ;  and,  in  addition  to  this,  the 
neck  hypertrophies,  and  becomes  more  at  a  right  angle  than 
it  normally  should  be.  This  results  in  elevation  of  the  tro- 
chanter above  Nelaton's  line  and  consequent  shortening  of 
the  leg. 

The  acetabulum,  on  the  other  hand,  is  deepened  by  the 
ossification  of  the  cotyloid  ligament  and  by  the  wearing 
away  of  the  floor  of  the  acetabulum,  which  is,  however,  gen- 
erally only  a  slight  matter. 


152  DISEASES    OF    THE    HIP    JOINT 


Synovial  Changes. 

The  synovial  membrane  in  the  early  stages  of  the  affection 
is  strongly  injected,  and  on  examination  appears  to  be  ab- 
normally red.  Synovial  effusion  may  be  considerable,  and 
in  the  early  stage  of  the  disease,  in  some  cases,  may  be  the 
only  objective  sign  of  the  impending  trouble.  Some  writers 
state  that  synovial  effusion  is  rarely  or  never  present  in 
rheumatoid  arthritis  (Senator,  Homolle,  etc.)  ;  but  practical 
experience  must  negative  that  assertion,  and  a  very  consider- 
able weight  of  authority  is  to  be  quoted  in  favor  of  the  fre- 
quent existence  of  effusion  (Brodie,  Adams,  Fuller,  Garrod). 

After  the  stage  of  acute  injection  the  synovial  membrane 
becomes  thickened,  and  the  synovial  fringes  are  greatly 
hypertrophied,  and  may  become  the  seat  of  fatty,  fibrous,  or 
cartilaginous  changes  to  a  marked  degree.  The  branching, 
tufted  appearance  of  these  fringes  may  be  so  marked  that  it 
is  spoken  of  as  lipoma  arborescens.  And  the  whole  appear- 
ance of  the  membrane  is  to  be  spoken  of  as  "  shaggy." 

The  change  to  fibrous  or  cartilaginous  tissue  in  the  fringes 
is  probably  due  to  the  fact  that  embryonic  cells  have  re- 
placed the  fat  in  the  synovial  fringes.  These  cartilaginous 
bodies  often  become  so  large  and  their  attachment  by  the 
synovial  fringe  is  so  small  that  they  become  pedunculated 
bodies,  ready  to  be  cast  loose  into  the  joint  at  any  time.  In 
certain  cases,  the  cartilaginous  bodies  in  the  synovial  fringes 
may  become  the  seat  for  the  deposit  of  lime  salts. 


Changes  in  Ligaments  and  Tendons. 

The  ligaments  become  inflamed  and  thickened,  and  degen- 
erate to  a  substance  like  fibro-cartilage ;  and  the  capsule  at 
the  same  time  suffers  a  similar  degeneration,  and  is  often 
the  seat  of  cartilaginous  deposits.  The  ligamentum  teres  de- 
generates to  a  frayed  out  fibrous  cord,  and  gradually  disap- 


ARTHRITIS    DEFORMANS    OF    THE    HIP   JOINT  1 53 

pears;  and  the  muscles  controlling  the  joint  become  pale 
and  wasted.  All  these  changes  of  course  do  much  to  impair 
the  joint's  mobility.  Finally,  in  the  severest  cases,  an 
ensheathing  bony  mass  begins  to  form  at  the  attached  bor- 
der of  the  capsule  and  in  the  ligaments,  which  progresses 
until  the  joint  is  splinted,  as  it  were,  in  a  dense,  compact, 
irregular  mass  of  bone,  which  prevents  mobility,  and  leads 
to  complete  obliteration  of  the  hip. 

Cysts  near  the  joint  may  form,  as  described  by  Mr.  Morrant 
Baker.  It  is  very  rare  in  connection  with  disease  of  the  hip 
joint ;  but  it  does  occur,  as  evidenced  by  one  recorded  case.* 
Such  cysts  are  formed  by  the  hernial  protrusion  of  a  dis- 
tended synovial  sac  into  the  periarticular  region. 

Etiology. 

The  antiquity  of  arthritis  deformans  f  is  attested  by  evi- 
dences of  its  existence  in  an  Egyptian  skeleton  of  the  Ptol- 
emaic period,  and  in  a  Roman  skeleton  found  in  a  sarcoph- 
agus at  Smithfield,  England. $  Chiaje  found  evidences  of 
the  disease  in  bones  unearthed  at  Pompeii,  and  the  Norse 
Viking  whose  remains  were  entombed  in  his  war-ship  in  the 
Christiania  fjord  was  a  sufferer  from  the  same  affection. 


Etiological  Theories. 

The  essential  character  of  the  affection  has  been  much 
disputed,  and  the  long  list  of  names  by  which  the  disease 
has  been  called  is  a  commentary  upon  the  various  views 
which  have  been  held. 

(i)  It  has  been  maintained  that  it  is  a  form  of  rheuma- 
tism, or  a  combination  of  rheumatism  and  gout. 

(2)  It  has  been  considered  by  Arbuthnot  Lane  that  it  is 

*W.  M.  Baker,  St.  Barth.  Rep.,  1885,  xxi.  p.  177. 

t  Eve.  British  Med.  Journal,  1890,  i.  423 ;  Lebert,  Hdbch.  d.  Pract.  Med.,  1859,  ii.  p.  874. 

J  Norman  Moore,  Path.  See.  Trans.,  1883,  p.  226;  Virchow's  Archiv,  1869,  xlvii.  298. 


154  DISEASES    OF    THE    HIP    JOINT 

not  a  disease  at  all,  but  that  the  articular  lesions  merely 
result  from  pressure. 

(3)  It  has  been  attributed  to  a  defective  nutrition  of  the 
joints,  due  to  a  disturbance  of  the  nervous  system. 

(i)  The  Rheumatic  Theory. —  Many  cases  of  chronic  artic- 
ular rheumatism  which  lack  the  distinctive  features  of  ar- 
thritis deformans  (the  destruction  of  cartilage  and  the  forma- 
tion of  exostoses)  are  continually  described  under  the  name 
of  arthritis  deformans  ;  and  the  distinction  is,  in  fact,  a  hard 
one  to  make  clinically,  so  that  for  this  reason  rheumatism 
and  arthritis  deformans  necessarily  become  confused.  In  a 
certain  proportion  of  cases,  arthritis  deformans  is  clearly 
dependent  upon  rheumatism,  occurring  in  rheumatic  individ- 
uals and  in  rheumatic  families.  This  proportion  is  a  vary- 
ing one,  and  each  writer  estimates  it  differently. 

But,  in  general,  it  would  seem  that  its  connection  with 
rheumatism  had  been  overstated.  In  most  cases,  it  begins 
as  arthritis  deformans,  and  is  not  preceded  by  an  attack  of 
acute  rheumatism.  It  affects  women  oftener  than  men,  which 
is  just  the  reverse  of  the  case  with  rheumatism,  and  the  old 
rather  than  the  young.  Exposure  is  a  causative  factor  in 
both  cases,  and  the  clinical  expression  is  much  like  rheuma- 
tisrn. 

But  it  seems  unwarrantable  to  assume  that  rheumatism 
exists  as  the  cause  of  arthritis  deformans  in  more  than  a 
certain  proportion  of  all  cases,  and  the  pathological  evidence 
would  seem  to  establish  an  independent  character  for  ar- 
thritis deformans  in  another  proportion  of  cases. 

In  the  same  way  with  gout,  it  can  be  said  that  arthritis 
deformans  in  many  instances  is  associated  with  and  proba- 
bly caused  by  gout ;  but  it  is  an  atypical  manifestation  of 
the  disease,  and,  although  in  very  many  instances  associated 
with  that  vague  condition  described  as  lithsemia,  the  disease 
cannot  be  described  as  a  gouty  one  in  more  than  a  small  pro- 
portion of  cases. 

In   typical  cases  of  arthritis  deformans,  it  must    be   said 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  I55 

that  sodium  urate  in  excess  is  not  found  in  the  blood  in  ar- 
thritis deformans,  and  that  the  symptoms  of  gout  (other  than 
the  articular  ones)  are  not  present. 

It  has  been  established  by  Sir  Dyce  Duckworth  that  in 
some  countries,  where  gout  is  all  but  unknown,  arthritis  de- 
formans is  a  very  common  affection.  In  Scotland  and  Ire- 
land, where  gout  is  very  uncommon,  arthritis  deformans 
prevails  to  a  marked  degree. 

It  is  for  these  reasons  that  the  writer  rejected  the  com- 
monest name  of  the  affection,  rheumatoid  arthritis,  and 
adopted  one  advancing  no  etiological  theory. 

(2)  The  Mechanical  Theory. —  Mr.  Arbuthnot  Lane  is  in- 
clined to  attribute  much  importance  to  the  effects  of  press- 
ure in  modifying  bone  structure ;  and  much  of  his  work 
has  been  highly  instructive  and  original,  as  in  his  discussion 
of  lateral  curvature  of  the  spine  and  bow-legs.  But,  in  at- 
tributing the  changes  in  arthritis  deformans  to  pressure 
effects  and  purely  mechanical  influences,  he  of  course  goes 
too  far.*  The  affection  of  the  finger  joints  in  women  who 
have  led  a  life  of  luxury,  and  nearly  all  the  phenomena  of  the 
disease,  tend  to  negative  his  ideas.  One  fact,  however,  calls 
attention  to  the  possible  value  of  this  theory.  The  fact  that 
senile  coxitis  often  follows,  and  seems  to  have  been  caused 
by  a  fall  upon  the  hip,  would  lead  one  to  suppose  that  a 
purely  mechanical  influence  was  in  many  cases  at  work,  and 
was  in  this  instance  the  cause  of  the  affection. 

(3)  The  DystropJiic  Theory  would  find  the  cause  of  the 
disease  in  some  disturbance  of  the  nervous  system,  either 
primary  or  reflex,  to  local  causes,  which  caused  trophic  dis- 
turbances of  the  joints.  This  theory  was  first  advanced  by 
Remak,f  and  at  present  is  advocated  by  such  authorities  as 
Duckworth,  Senator,  and  Ord. 

Of  late  much  weight  has  been  given  to  this  view  by  the 
fact  that  the   pathological  changes  in  the  arthropathies  of 

*W.  A.  Lane,  Path  Soc.  Trans.,  1884,  xxxv.,  and  1886,  xxxvi.  p.  387. 
t  Galvano-therapie,  1858;  also  Deutsch.  Klinik,  1863,  p.  107. 


156  DISEASES    OF    THE    HIP    JOINT 

tabes  and  similar  affections  seem  to  be  only  an  intensifica- 
tion of  the  ordinary  changes  in  arthritis  deformans.  That 
is,  where  we  know  that  a  lesion  of  the  nervous  system  exists 
we  find  articular  changes  of  a  character  similar  to  those  of 
arthritis  deformans,  only  more  acute.  In  Charcot's  disease 
the  destructive  processes  predominate  over  the  formative 
activity,  but  the  erosion  of  cartilage  and  the  formation  of 
osteophytes  are  present  in  both. 

The  symmetrical  distribution  of  arthritis  deformans  in  so 
large  a  proportion  of  all  cases  is  thought  by  some  writers  to 
show  the  existence  of  some  central  nervous  disturbance;  but 
Sir  James  Paget  puts  it  on  broader  ground  in  saying  that 
symmetrical  lesions  are  due  to  diseases  in  which  the  origin 
of  the  morbid  process  is  in  the  condition  of  the  circulating 
fluid.  Dr.  Ord  and  others  would  infer  that  a  nervous  dis- 
turbance was  the  cause  of  the  affection  from  the  fact  that 
uterine  derangements  so  often  stand  in  a  causal  relation,  and 
he  alludes  to  the  great  power  of  uterine  irritation  in  produc- 
ing excitement  of  the  spinal  cord.  Senator  lays  stress  upon 
the  fact  that  emotional  and  mental  disturbance  have  an  effect 
in  producing  and  increasing  arthritis  deformans,  as  they  have 
in  the  case  of  nervous  disease  proper. 

Again,  writers  who  favor  this  dystrophic  theory  would  find 
an  argument  for  nervous  influence  in  the  existence  of  mus- 
cular atrophy ;  but  there  is  no  evidence  whatever  to  show 
that  it  is  not  an  arthritic  atrophy,  such  as  is  found  in  all 
joint  disease  of  any  such  severity. 

In  short,  the  dystrophic  theory  rests  on  a  very  slender 
basis  of  facts,  and  is  strictly  a  theory,  and  nothing  more.  It 
seems  to  call  attention  to  the  fact  that  general  disturbance 
of  the  system  is  most  often  present,  and  that  cold,  exposure, 
uterine  derangements,  and  all  conditions  which  depress  the 
general  health  are  active  as  factors  in  causing  the  disease. 
But  (except  for  the  similarity  of  the  disease  to  tabetic  arthro- 
pathy) the  advocates  of  this  theory  signally  fail  to  prove  the 
existence  of  a  nervous  causation  of  the  disease. 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  1 57 

These  three  theories  show  certain  important  points  in 
connection  with  the  etiology  of  arthritis  deformans :  that 
it  is  often  associated  with  rheumatism  or  gout,  but  in  a 
large  proportion  of  all  cases  exists  as  a  separate  disease ;  and 
that  it  is  favored  by  all  causes  which  depress  the  general 
condition  or  lower  the  vitality,  although  it  cannot  be  proved 
that  such  causes  act  through  the  nervous  system  rather  than 
through  the  general  circulation. 

Traumatism. —  The  place  of  traumatism  as  a  cause  of 
malum  coxae  senile  is  not  generally  allowed  so  much  weight 
as  it  would  seem  to  deserve.  It  is  a  frequent  cause  of  the 
affection,  and  was  first  clearly  recognized  by  Canton  in  1855.* 
Much  attention  was  attracted  by  the  case  of  the  elder 
Charles  Matthews,  who  fell  and  injured  his  hip  when  he  was 
forty  years  old,  and  who  was  treated  unsuccessfully  by  the 
most  eminent  surgeons  of  his  time.  At  the  end  of  ten  years 
of  lameness  and  partial  disability  he  died  of  some  other 
disease;  and  in  his  hip  were  found  the  evidences  of  chronic 
arthritis  deformans,  a  fact  which  at  the  time  excited  much 
notice. 

Since  then  it  has  been  recognized  that  people  after  middle 
life  who  are  so  unfortunate  as  to  fall  and  bruise  the  hip,  not 
uncommonly  suffer  from  pain,  progressive  disability,  and 
shortening  of  the  leg;  and  in  such  joints  are  found  the 
characteristic  changes  of  arthritis  deformans. 

The  rationale  of  the  process  is  but  little  understood,  and 
the  fact  must  be  accepted  as  it  stands.  It  occurs  much 
oftener  as  a  cause  of  the  disease  in  the  hip  than  elsewhere ; 
and,  in  the  majority  of  hips  affected,  the  history  of  an  acci- 
dent can  be  found. 

Injury  may  cause  multiple  as  well  as  single  joint  disease, 
as  in  a  case  related  by  Garrod,  where  a  patient  was  kicked 
in  the  hip  by  a  horse,  and  sixteen  years  later  had  the  affec- 
tion in  the  joints  of  the  fingers,  in  the  right  shoulder  and 
right  hip,  the  onset  of  which  he  traced  back  to  the  injury. 

*Surg.  and  Path.  Observations  on  "  Shortening  of  the  Leg  from  Bruise  of  the  Hip." 


158  DISEASES    OF    THE    HIP    JOINT 

The  hip  alone  was  affected  for  ten  years,  and  then  the  other 
joints  became  involved. 

Localized  rheumatoid  arthritis,  affecting  the  hip  alone, 
occurs  more  often  in  men  than  women,  which  is  the  reverse 
of  the  state  of  affairs  in  the  more  general  manifestations  of 
the  affection. 

Heredity. —  Hereditary  influence  is  less  marked  than  in 
gout  or  rheumatism.  Charcot  obtained  a  history  of  arthritis 
deformans  in  the  parents  of  11  out  of  41  patients  questioned.* 
In  500  of  Garrod's  patients  with  arthritis  deformans  a  fam- 
ily history  of  such  an  affection  was  present  in  84,  while  64 
showed  a  family  histor}-  of  gout  and  48  of  rheumatism. f 

Age. —  The  disease  is  essentially  one  of  early  old  age  ;  and, 
although  occasionally  one  sees  instances  of  the  polyarticu- 
lar form  in  children, t  the  writer  has  never  seen  an  instance 
of  it  in  the  hip.  Occurring  in  the  hip  joint  alone  in  a  child, 
it  would  almost  surely  escape  detection  during  life,  however; 
for  the  symptoms  would  differ  but  little  from  those  of  ordi- 
nary hip  disease.  The  table  of  Garrod  shows  the  distribu- 
tion of  the  disease  by  age  :  — 

Under  9  years 3 

10-19        22 

20-29       64 

30-39  85 

4c^49  121 

50-59  no 

60-69  72 

70-79  5 

80-90  I 

In  women  it  seems  closely  connected  with  the  cessation 
of  the  menses  in  very  many  cases.     Of  411  female  patients 

*  Charcot,  These  de  Paris,  1853.  t  Garrod,  A  Treatise  on  Rheumatism,  p.  239. 

fDally,  Jonm.  de  Therap.,  1S7S,  14;  DuraDd  Farrell,  Union  Med.,  iSSi,  xxrii.;  Gazette  des 
Hop.,  1SS2,  -So.  116;  Henoch,  Kinderk'h'ten ,  1SS3,  p.  72S:  Mantisen,  These  de  Paris,  1S84; 
Moncows,  Rh.  Chronique  Noueuxdes  Enf.,  iSSo;  Wagner,  Miinchener  Med.Wchnsft.,iSSS,  xxxv.; 
Weil,  Nouvelle  Iconographie  de  la  Salpetiere,  1S90,  i.  p.  16. 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  1 59 

the  disease  began  in  i8  in  the  two  years  preceding  the  men- 
opause, and  in  41  in  the  two  years  following  it. 

Sex. —  In  the  polyarticular  variety  women  are  much  more 
commonly  the  victims,  no  less  than  411  of  Garrod's  500  pa- 
tients being  females.  When  the  hip  alone  is  affected,  men 
are  affected  rather  more  commonly  than  women. 

Uterine  derangemejit  is  a  very  frequent  cause  of  arthritis 
deformans.  Dr.  Ord  *  reported  38  cases  of  the  disease  in 
women  of  all  stations,  and  in  30  of  them  some  uterine  diffi- 
culty was  present.  It  is  questionable  whether  such  de- 
rangements act  directly  in  causing  the  disease  or  merely  by 
lowering-  the  general  condition. 


Mental  and  Emotional  Causes. 

Mental  shocks  are  thought  to  be  occasional  causes  of  the 
affection.!  Leyden  states  that  many  of  those  who  suffer 
from  arthritis  deformans  in  Strassburg  attribute  the  com- 
mencement of  it  to  frights  received,  chiefly  by  the  exploding 
shells,  during  the  bombardment  of  the  city  in  1876.$  Pro- 
longed worry,  mental  overwork,  and  protracted  mental  anx- 
iety have  a  marked  influence  in  many  instances  in  causing 
and  a.ggravating  the  disease. 

Dampness  and  exposure  are  two  of  the  more  common 
causes  in  the  disease  as  it  appears  in  the  lower  classes. 
Joined  with  these  two  conditions,  one  finds  generally  bad 
hygiene  and  insufficient  food.  With  regard  to  these,  as  to 
the  preceding  causes,  it  must  be  said  that  it  is  not  clear 
whether  they  act  directly  or  by  depressing  the  general  con- 
dition. 

Treatment. 

The  treatment  can  best  be  discussed  as  general  and  local. 
In  the  case  of  the  disease  as  it  affects  the  hip,  local  meas- 

*Brit.  Med.  Journal,  1S84,  ii.  p.  26S.  t  Kolits,  Kl.  Wchsft.,  1S73,  p.  304. 

+  Klinik  der  Riickenmarkskrankheiten,  1874,  p.  270. 


l60  DISEASES    OF    THE    HIP    JOINT 

ures  are  of  such  importance  that  they  deserve  the  first  con- 
sideration, especially  as  they  are  very  generally  left  out  of 
account,  and  senile  coxitis  is  merely  treated  on  general 
principles. 

Local  Treatment. 
Mechanical. 

Certain  theoretical  considerations  should  suggest  the 
propriety  of  local  treatment.  These  are  the  fact  that  in  so 
many  cases  the  disease  is  caused  by  traumatism,  whence  it 
would  seem  proper  to  avoid  the  further  traumatism  of  walk- 
ing by  protecting  the  joint.  The  fact  that  the  joint  is  in  a 
condition  of  inflamm.ation  and  that  walking  is  painful  would 
also  seem  to  indicate  the  propriety  of  joint  rest. 

The  theoretical  objection  to  joint  rest  would  be  found  in 
the  fear  that  it  would  favor  anchylosis. 

Patients  with  senile  coxitis  suffer  much  from  pain,  muscu- 
lar spasm,  and  sensitiveness  of  the  joint  in  walking.  This 
symptom  group  is  the  expression  of  joint  irritation,  and  is 
associated  in  arthritis  deformans,  as  has  been  seen,  with  a 
low  grade  of  synovitis. 

Rest  in  bed,  with  traction  if  necessary,  will  do  much  to 
quiet  this  discomfort.  The  stiffness  is  in  the  early  stages 
the  result  of  muscular  contraction,  and  not  of  anchylosis,  and 
is  diminished  rather  than  increased  by  any  measure  which 
quiets  the  irritability  of  the  joint. 

Traction  is  indicated  in  all  cases  where  passive  manipula- 
tion of  the  hip  is  painful  and  restricted  by  muscular  spasm, 
and  in  cases  where  pain  is  continuous  and  excessive.  The 
patient  should  lie  in  bed  with  a  weight  and  pulley  arranged 
for  traction,  as  described  under  ordinary  hip  disease.  The 
weight  should  be  five  pounds  or  more  or  less  according  to 
circumstances,  and  should  pull  in  the  normal  direction  of 
the  leg  ordinarily;  but,  exceptionally,  it  will  be  found  neces- 
sary to  allow  for  malposition  of  the  limb  and  to  make  traction 
in  the  line  of  the  deformity. 


ARTHRITIS    DEFORMANS    OF    THE    HIP   JOINT 


l6l 


The  weight  should  be  enough  to  ease  the  pain  without 
tiring  the  leg  too  much  ;  and  traction  should  be  continued 
for  some  days,  or  perhaps  two  or  three  weeks,  when  in  most 
instances  much  improvement  of  the  joint  will  be  noted,  and 
motion  will  be  more  free  and  less  painful. 

Nowhere  is  traction  of  greater  benefit,  and  nowhere  is  the 
relief  from  its  use  more  quickly  noticed,  than  in  senile 
coxitis-. 

After  the  pain  and  irritability  are  con- 
trolled, the  patient  should  be  allowed  to  go 
about;  but  the  joint  should  be  protected 
from  jar  and  traumatism,  and  this  is  best 
done  by  the  convalescent  hip  splint  men- 
tioned above.  In  this  way  the  patient  gets 
out  of  doors,  and  the  joint  is  exercised  within 
narrow  limits,  while  pressure  and  the  con- 
stant jar  are  removed ;  and  such  splints 
should  be  jointed  at  the  knee. 

Such  a  splint  should  be  worn  during  the 
day,  and  exercise  encouraged.  If  sensitive- 
ness returns,  the  patient  should  be  sub- 
jected for  a  few  days  to  rest  in  bed  and 
weight  and  pulley  traction. 

The  results  of  treatment  by  this  method 
are  surprisingly  good ;  and  such  patients  are 
much  more  comfortable  than  if  dependent 
on  crutches,  while  it  is  a  treatment  which 
is  capable  of  producing  much  permanent 
benefit.  The  only  article  dealing  with  this 
aspect  of  the  subject  with  which  the  writer 
is  familiar  is  the  admirable  one  of  Dr.  H.  L. 
Taylor.* 

Other  Measures  of  Local  Treatment. 


Fig.  49. —  PROTEC- 
TION SPLINT  FOR  THE 
HIP. 


Other  measures  must  be  regarded  as 


Counter-irritation. 
only   accessory.     Counter-irritation    is    of   use   in    many  in 


*N.Y.  Med.  Journal,  Dec.  15,  i? 


l62  DISEASES    OF    THE    HIP    JOINT 

Stances.  Perhaps  as  efficient  a  form  of  relieving  the  pain  as 
any,  when  traction  fails  or  is  not  available,  is  by  the  use  of 
the  Pacquelin  cautery,  which  should  be  lightly  and  very 
quickly  drawn  over  the  skin,  leaving  a  very  superficial  and 
almost  painless  eschar.  The  sensation  is  as  if  a  mustard 
plaster  had  been  over  the  hip.  Liniments  and  blisters  may 
at  times  be  of  use,  but  the  effect  of  all  these  is  only  tempo- 
rary and  palliative.  Hot  applications  are  useful  in  painful 
hip  joints  alone,  or  especially  in  connection  with  treatment 
by  rest  and  traction. 

Massage  may  be  of  much  benefit  in  senile  coxitis,  espe- 
cially where  the  sensitiveness  of  the  joint  has  been  controlled 
and  it  is  desired  to  develop  as  far  as  possible  the  wasted 
muscles.  It  should  not  be  carried  to  the  extent  of  develop- 
ing pain,  and  joint  manipulation  should  not  be  carried  to  a 
painful  point  under  any  circumstances.  The  object  of  mas- 
sage is  to  stimulate  the  local  circulation,  to  promote  the 
absorption  of  the  diseased  products,  and  to  provide  exercise 
within  safe  limits  to  the  diseased  limb.  It  is  not  to  be  re- 
garded as  a  means  of  breaking  down  adhesions  or  of  roughly 
extending  the  arc  of  motion  of  the  joint.  If  such  a  process 
were  considered  desirable,  it  should  be  done  under  ether;  but 
experience  has  shown  that,  although  temporarily  a  greater 
degree  of  joint  motion  may  be  obtained  by  such  forcible 
manipulation,  a  greater  degree  of  stiffness  follows  after  a 
short  time. 

Massage  should  ordinarily  be  given  every  other  day,  and, 
as  has  been  said,  it  is  not  so  well  adapted  to  the  painful 
stage  of  the  affection  as  to  the  quiescent  period  which  suc- 
ceeds good  mechanical  treatment.  In  cases  where  the 
latter,  is  not  obtainable,  massage  may  be  of  use  if  gently 
given  in  connection  with  rest  and  hot  application. 

Electricity  is  often  of  much  use  in  senile  coxitis,  chiefly  as 
it  modifies  the  circulation  and  improves  the  local  nutrition. 
It  is  for  this  reason  that  the  galvanic  is  the  more  beneficial 
of  the  two  forms. 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  163 


General  Treatment. 

It  was  formerly  supposed  that  therapeutic  measures  had 
little  power  over  arthritis  deformans.  Later  years  have 
shown  that,  although  the  disease  is  one  which  is  not  easily 
controlled,  it  is,  nevertheless,  in  most  cases  susceptible  of 
much  improvement.  Where  senile  coxitis  exists  alone,  less 
is  to  be  expected  from  general  measures  of  treatment  than 
where  it  coexists  with  the  affection  of  the  other  joints. 

Drugs. —  The  long  list  of  drugs  is  a  sufficient  commentary 
upon  the  ill  success  of  a  purely  medicinal  treatment. 

Iodide  of  potash,  iodine,*  arsenic,!  lithia  and  its  salts, 
cimicifuga,  the  salicylates, |  alkaline  diuretics,  quinine,  and 
similar  tonics,  Fraxinus  excelsior  (Fuller),  Actoea  racemosa 
(Ringer),  ichthyol  (Lorenz),  and  many  less  important  drugs 
have  been  advocated  as  beneircial.  The  drug  treatment 
advocated  by  each  writer  is,  as  a  rule,  a  matter  of  personal 
opinion ;  and  widely  differing  results  are  obtained  from  the 
same  treatment  by  different  authors. 

The  first  essential  is  that  the  general  condition  should  be 
kept  as  good  as  possible.  If  the  appetite  is  poor,  bitter 
tonics  are  indicated,  the  bowels  should  be  kept  in  good  order, 
and  a  general  regime  followed  out  which  should  aim  at  keep- 
ing the  patient  in  the  best  possible  condition  in  every  partic- 
ular. It  is  unnecessary  to  say  that  there  is  no  specific  for 
arthritis  deformans.  The  writer  has  obtained  better  results 
with  the  salicylate  of  soda  and  alkaline  diuretics  than  with 
any  other  drugs.  The  patients  have  taken  five  or  ten  grains 
of  salicylate  of  soda  after  meals  for  long  periods,  and  with 
the  meals  some  mild  diuretic,  such  as  Vichy  water  or  the 
artificial  effervescent  salt.  A  simple  and  nutritious  diet  has 
been  enforced,  avoiding  large  quantities  of  meat  and  taking 
from  one  to  two  quarts  of  milk  daily.     Where  milk  has  been 

*  Lasegne,  Arch.  Gen.  de  Med.,  1S56,  viii.  300. 

t  De  Miissy,  Bull.  G^n.  de  Th^r.,  1864,  Ixvii.  241. 

+  Lancet,  18S2,   p.  141 ;    See,  Bull,  de  I'Acad.  de  M^d.,  1S77,  v.  689. 


164  DISEASES    OF    THE    HIP   JOINT 

badly  borne,  a  measured  quantity  of  water  has  been  pre- 
scribed. 

With  regard  to  this  treatment  the  writer  can  only  speak  of 
his  own  experience,  which  is  that  the  majority  of  patients 
improve  perceptibly  under  such  a  regime  as  this,  while  some 
are  relieved  of  their  symptoms  to  a  large  extent.  This, 
however,  is  not  so  likely  to  happen  in  arthritis  deformans  of 
the  hip  as  where  it  is  more  generally  distributed.  Such  a 
treatment  should,  however,  be  pursued  in  connection  with 
the  local  measures  advocated. 

Climatic  Treatment. —  Persons  affected  with  arthritis  de- 
formans are,  as  a  rule,  more  comfortable  in  warm  weather 
and  in  warm  climates  than  in  cold.  Certain  localities  seem 
to  exercise  a  very  favorable  influence  on  the  disease,  espe- 
cially in  connection  with  the  various  baths  and  springs  to  be 
found  at  such  health  resorts. 

In  America  the  Hot  Springs  of  Arkansas  deserve  the 
first  mention,  while  Richfield  Springs  in  Central  New  York 
are  often  of  benefit.  But  either  place  is  inferior  to  some 
of  the  more  widely  known  and  better  organized  resorts  in 
Europe. 

Aix-les-Bains  *  is,  perhaps,  as  well  known  as  any  place 
where  massage  and  hot  douches  constitute  the  essential  part 
of  the  treatment.  In  England  the  same  measures  are  em- 
ployed at  Bath.  Harrowgate  and  Buxton  are  other  English 
resorts.  On  the  continent  one  finds  Bourboule,  Aix-la-Cha- 
pelle,  and  Mont  Dore  especially  advocated  for  these  affec- 
tions ;  while  resorts  of  a  wider  range  of  applicability  are 
Homburg,  Carlsbad,  Vichy,  Wildbad,  Marienbad,  Kissingen, 
and  similar  spas,  and  these  are  much  resorted  to  by  patients 
with  arthritis  deformans. 

With  regard  to  the  relative  importance  of  general  and  local 
treatment,  the  writer  would  be  glad  once  more  to  emphasize 
his  belief  in  the  great  benefit  to  be  derived  from  rational 
mechanical  treatment,  consisting  in  joint  rest  and  protection, 

*Garrod,  Lancet,  1S89,  i.  S69. 


ARTHRITIS    DEFORMANS    OF    THE    HIP    JOINT  165 

with  traction  where  indicated.  Massage,  electricity,  etc.,  he 
would  regard  merely  as  measures  of  secondary  importance, 
which  should  facilitate  and  assist  this  main  line  of  treatment. 
From  the  combination  of  these,  very  satisfactory  results  are, 
in  many  cases,  to  be  obtained  in  arthritis  deformans  of  the 
hip. 

In  short,  joint  irritation  due  to  arthritis  deformans  is  to 
be  met  by  the  same  measures  as  joint  irritation  due  to 
other   causes. 

Other  References. 

Althaus,  Brit.  M.  J.,  1872,  p.  211,  ii.  (electricity) ;  Bardele- 
ben,  Lehrb.  d,  Chir.,  ii.,  Berlin,  1880;  Bardsley,  Med.  Rep., 
1807  (arsenic);  Brachet,  Brit,  M.  J.,  1884,  ii.  p.  411  ;  Bene- 
dict, Wiener  Med.  Halle,  1864;  Baker,  W.  M.,  St.  Barth. 
Hosp.  Rep.,  1877,  xiii.  ;  1885,  xxi.  p.  177  ;  Cheron,  Gaz.  des 
Hop.,  1869,  No.  150  (elect.);  Drachmann,  Virch.  Jahresber., 
1873;  Duckworth,  Br.  M.  J.,  1884,  ii,  263;  Echer,  Arch,  f, 
Phys.  Heilkunde,  1843  ;  Giirlt,  Beitr.  z.  Path.  Anat.  d. 
Gelenkkrankheiten,  Berlin,  1853  ;  Meyer,  Berl.  Kl.  Wchsft., 
1870,  p.  265  ;  Moore,  N.,  Path.  Soc.  Trans.,  1883,  xxiv.  ; 
Nuscheler,  Zeitsch.  f.  Rar.  Med.,  1855  ;  Popu,  These  de 
Paris,  1881  ;  Rhoden,  D.  Med.  Wchsft.,  1876;  Riess,  Eulen- 
burg's  Real  Encycl. ;  Remak,  Galvano-therapie,  1858,  413; 
Schomann,  D.  Malum  Coxae  Senile,  Jena,  185 1  ;  Trastour, 
Bull.  Gen  de  Ther.,  1879,  cxvii.  509;  Volkmann,  Hdbch,  d. 
Chir.  von  V.  Pitha  und  Billroth,  ii.,  1872;  Virchow,  V. 
Arch.,  Bd.  4  and  47 ;  Weber,  V.  Arch.,  Bd.  xiii.  ;  Wehrner, 
Beitrg.  zur  Kennt.  d.  K'h'ten  d.  Hiiftgelenkes,  Giessen,  1847; 
Wymer,  Lancet,  1889,1.  933;  Ziegler,  Pathol.  Anat.,  1887, 
5th  ed.,  p.  169. 


l66  DISEASES    OF    THE    HIP    JOINT 


Chapter  IX. 
CHARCOT'S   DISEASE    OF   THE    HIP   JOINT. 

A  CURIOUS  affection  of  the  joints  has  been  described  by 
Charcot,  which  occurs  in  connection  with  certain  affections 
of  the  nervous  system.  The  affection  is  consequently  most 
often  called  by  his  name,  while  other  terms  in  common  use 
are  spinal  arthropathy,  tabetic  arthropathy,  and  arthropathy. 

Pathology. 

The  pathological  changes,  it  has  already  been  said,  are 
similar  to  those  of  arthritis  deformans,*  although,  as  a  rule, 
more  rapid  and  destructive,  and  possessing  an  occasional 
tendency  to  suppuration,  which  is  almost  unknown  in  that 
disease.  Moreover,  the  effusion  is  generally  more  extensive, 
and  the  role  played  by  the  synovial  membrane  is  a  more 
active  one  than  in  arthritis  deformans. 

The  synovial  membrane  goes  through  the  stages  of  a 
chronic  synovitis,  and  becomes  thickened,  succulent,  and 
pale,  finally  passing  on  to  a  granular  condition  in  cases 
which  suppurate. 

The  cartilage  degenerates,  and  the  ends  of  the  bones  are 
exposed,  to  rub  together  and  wear  each  other  away,  and,  if 
suppuration  should  be  present,  to  melt  down  into  pus. 

At  times  bony  overgrowth  prevails,  when  the  ends  of  the 
bones  are  much  enlarged  and  irregular,  while  at  other  times 
they  are  atrophied  and  fragile.  Spontaneous  fracture  and 
dislocation  may  occur.     The  capsule  becomes  thickened  in 

*Virchow,  Cent.  £.  Chir.,  18S7,  No.  22,  p.  417. 


Charcot's  disease  of  the   hip  joint  167 

some  cases,  and  perhaps  invaded  by  the  osteophytes,  while 
in  other  cases  it  degenerates  and  disappears,  as  does  in  most 
instances  the  ligamentum  teres.  There  is  generally  much 
thickening  of  the  trochanter,  and  periarticular  infiltration 
occurs  in  most  of  the  cases  to  a  very  marked  degree. 

Microscopic  examination  shows  in  the  atrophic  form  the 
changes  of  rarefying  ostitis,  a  widening  of  the  Haversian 
canals,  and  their  coalescence  with  the  general  cavity  of  the 
medulla,  thinning  of  the  trabeculae,  etc. 

Cases  in  which  the  early  pathological  condition  can  be 
investigated  are  not  common.  Where  it  has  been  possible 
to  do  so,  the  synovial  membrane  has  been  found  smooth,  and 
the  fringes  hypertrophied  to  form  tufts.  The  synovial  effu- 
sion is  generally  serous,  and  only  seldom  a  purulent  one. 
The  capsule  is  thickened,  and  the  bones  are  either  atrophied 
or  hypertrophied.  If  atrophied,  the  rim  of  the  acetabulum 
is  lowered,  and  the  cavity,  although  more  shallow  than  nor- 
mal, is  broader.  The  hypertrophic  form  shows  bony  over- 
growth, much  as  in  arthritis  deformans. 

A.  S.  Roberts  classifies  the  pathological  changes,  perhaps 
more  systematically,  as  follows  :  (i)  a  chronic  asthenic 
hyperasmia  of  the  synovial  membrane  (hydrarthrosis)  ;  (2) 
an  interstitial  atrophy  of  the  epiphyses ;  (3)  a  fungous  or 
rarefying  hypertrophy  of  the  epiphyses ;  (4)  the  formation 
of  bony  stalactites.  These  conditions  may  exist  separately, 
but  some  combination  of  them  is  more  common  than  any 
one  alone. 

Analysis  of  affected  bones  shows  that  the  fat  is  increased, 
while"  phosphorus  and  calcium  are  diminished,  when  com- 
pared with  normal  bone.  This  is  practically  the  same  state 
of  affairs  as  in  osteomalacia. 

Associated  with  the  joint  changes  are  apt  to  be  such 
trophic  disturbances  as  dystrophy  of  the  nails,  muscular 
atrophy,  etc. 


l68  DISEASES    OF    THE    HIP    JOINT 


Etiology. 


This  condition  of  the  joints  occurs  most  commonly  in 
locomotor  ataxia  (tabes  dorsalis),  and  is  most  known  in  its 
connection  with  that  disease.  But  it  is  found  at  times  also 
in  acute  myelitis  and  the  paralysis  of  Pott's  disease,  in 
hemiplegia  and  disseminated  sclerosis,  in  progressive  mus- 
cular atrophy,  in  syringomyelia,  in  connection  with  some 
tumors  occupying  the  gray  matter  of  the  cord,  and  in  cer- 
tain traumatic  lesions  of  the  spinal  cord.  In  short,  a  joint 
disease  of  this  type  is  likely  to  occur  in  any  lesion  of  the 
cells  of  the  anterior  cornua  of  the  cord.* 

The  disease  affects  the  knee  most  often  of  all  the  large 
joints,  and  the  hip  comes  next  in  the  order  of  frequency. 
In  Weizsacher's  cases,  of  169  joints  analyzed  the  knee  was 
affected  78  times,  the  hip  31  times,  the  shoulder  21,  the 
tarsus  13,  etc.  Most  often  one  joint  is  affected,  but  occa- 
sionally two  or  more  are  involved.  The  169  diseased  joints 
mentioned  above  occurred  in  109  individuals.  The  right  and 
the  left  side  of  the  body  are  affected  with  equal  frequency. 

The  joint  affection,  as  a  rule,  occurs  at  a  comparatively 
early  stage  in  the  spinal  cord  disease. 

The  frequency  of  the  affection  is  but  little  known.  In  56 
cases  of  tabes,  Erb  observed  joint  trouble  in  only  2. 

Of  109  cases  collected  by  Weizsacher,  72  were  men  and  37 
were  women. 

The  identity  of  this  affection  has  been  a  matter  of  much 
discussion.  It  has  been  asserted  that  it  was  only  the  result 
of  constant  traumatisms  to  a  joint  whose  sensation  was  de- 
stroyed. Just  as  the  section  of  the  facial  nerve  destroys  the 
sensitiveness  of  the  eye  and  renders  it  unconscious  of  harm- 
ful substances  which  may  be  rubbing  it,  so,  it  has  been 
asserted,  do  these  joints  become  inflamed  and  injured  from 

*  Charcot,  vol.  i.  p.  121 ;  Michaud.  Sur  le  Meningite  et  Myelite  dansle  Mai  Vert,  Paris,  1871 ; 
Gull,  Guy's  Hosp.  Rep.,  1S5S;  Daun,  Lancet,  1S31,  ii.  p.  235;  Cent.  f.  Chir.,  1887,  Nos.  22,  25, 
and  42  ;  Phila.  Medical  Times,  April  iS,  1868. 


Charcot's  disease  of  the  hip  joint  169 

the  fact  that  the  patient  does  not  feel  pain  from  slight  trau- 
matisms, and  guard  his  joint  accordingly.  But  this  theory- 
has  fallen  into  discredit,  because  the  joint  affection  is  often 
found  where  the  disturbances  of  co-ordination  are  slight  and 
not  enough  to  account  for  rough,  inco-ordinated  use  and  in- 
sensitiveness  of  the  limb.  This  is  the  condition  in  most 
cases.* 

The  present  disposition  is  to  regard  the  affection  as  a  dis- 
tinct entity,  and  not  as  a  form  of  either  arthritis  deformans 
or  syphilitic  disease  of  the  joints,  both  of  which  it  resembles 
pathologically.  Virchow  attributes  the  destruction  to  a 
faulty  cellular  change  in  the  affected  joint,  which  amounts 
merely  to  calling  it  a  trophic  change,  which  explains  very 
little.  It  must  be  accepted  as  such,  however,  in  the  absence 
of  more  definite  pathological  knowledge. 

Treatment. 

The  treatment,  of  course,  should  aim  at  controlling,  so  far 
as  possible,  the  spinal  cord  disease,  whatever  may  be  its 
nature.  For  the  joint  disease  but  little  can  be  done,  from 
the  nature  of  the  case.  If  syphilis  is  present,  mercury,  and 
especially  iodide  of  potash,  are  indicated,  and  in  some  cases 
have  a  very  favorable  effect  upon  the  local  condition.  In 
many  of  the  cases  it  may  be  desirable  to  keep  the  joint  at 
rest,  which  will  limit  or  retard  the  destructive  process ;  but 
such  joints  are  not  commonly  painful,  and  motion  is  likely 
to  be  somewhat  restricted  by  nature  through  the  periartic- 
ular swelling  and  the  degeneration  of  the  capsule  in  the 
hypertrophic  cases. 

If  the  swelling  is  excessive  from  joint  distension,  aspira- 
tion will  give  relief  temporarily. 

Apparatus  is  of  little  use  except  to  fix  the  limb  in  painful 
cases,  and  the  motor  disability  of  these  patients  would  often 
contra-indicate  the  use  of  anything  more  than  bed  traction. 

*  Weizsacher,  Beitrage  zur  Klin.  Chir.,  Bd.  iii.  Hft.  i. 


170  DISEASES    OF    THE    HIP    JOINT 

Excision  of  the  joints  has  been  done  in  some  cases  with 
fair  success  at  the  knee,  but  at  the  hip  nothing  seems  likely 
to  be  accomplished,  because  in  the  severer  cases  the  process 
of  disease  will  lead  to  a  result  which  is  practically  a  sponta- 
neous excision ;  and  so  extensive  an  operation  in  tissue  with 
so  little  reparative  power  would  seem  to  be  hardly  justified. 

Incision  may  be  necessary  for  the  evacuation  and  drainage 
of  pus. 


MALIGNANT    AND    OTHER    TUMORS    OF    THE    HIP  I7I 


Chapter  X. 

MALIGNANT   AND    OTHER   TUMORS   OF 
THE    HIP. 

.    ^  Malignant  Disease  of  the  Hip  Joint. 

Malignant  disease  of  the  hip  occurs  very  rarely,  yet 
often  enough  to  make  it  worthy  of  careful  consideration. 
In  nearly  all  cases,  the  malignant  growth  is  a  sarcoma.  But 
formerly  such  tumors  were  classified  as  cancers;  and,  for 
this  reason,  it  seems  worth  while  to  discuss  somewhat  care- 
fully the  structure  and  pathological  characteristics  of  sar- 
coma of  bone,  as  accepted  by  modern  writers.  Although 
excessively  rare,  carcinoma  of  bone  is  not  unknown.  Ziegler 
states  that  primary  cancer  of  bone  never  occurs.  On  the 
other  hand,  Virchow,  Volkmann,  Forster,  and  Paget  believe 
that  primary  cancer  of  bone  is  occasionally  to  be  met.  How- 
ever that  may  be,  in  nearly  all  cases  one  has  to  deal  with 
sarcoma,  and  it  is  that  which  should  claim  the  first  con- 
sideration. 

Sarcoma  of  the  Hip. 

The  name  of  osteosarcoma  should  be  restricted  to  the 
description  of  those  cases  where  ossification  is  present  in 
the  tumor  to  some  extent.  The  name  has  been  loosely 
applied  to  all  the  sarcomas  of  bone  by  many  writers ;  but 
modern  usage  is  restricting  it  to  that  especial  significance, 
and  using  the  simple  term  sarcoma  in  connection  with  the 
ordinary  cases. 

For  our  knowledge  of  the  pathology  of  malignant  growths 
of  the  bones  we  are  largely  indebted  to  the  classical  papers 
of  Dr.  S.  W.  Gross,*  who  has  analyzed  165  cases  of  sarcoma 

•Am.  Journ.  Med.  Sci.,  July  and  October,  1879. 


172  DISEASES    OF    THE    HIP    JOINT 

of  the  long  bones.  He  is  inclined  to  attribute  much  clinical 
importance  to  the  variety  of  the  sarcomatous  growth,  a 
matter  in  which  German  pathologists  do  not  agree  with 
him  ;  and  in  malignant  tumors  of  the  hip  joint  the  matter 
possesses  practically  no  significance. 

There  are  two  large  divisions  of  sarcomas  which  are  of 
practical  importance.  They  are  either  central  or  periosteal. 
In  most  instances,  the  central  growths  are  of  giant-celled 
variety,  while  the  periosteal  tumors  are  composed  of  spindle 
cells.  Central  tumors  are  generally  spherical,  when  seated 
in  the  epiphyses,  and  on  section  are  seen  to  be  dark  red  and 
moist,  with  perhaps  an  admixture  of  bony  spicules. 

Periosteal  tumors,  on  the  other  hand,  are  more  fusiform  in 
shape  and  of  greater  density ;  and  the  tissue  composing 
them  is  grayish  white  and  dense.  Here,  also,  bony  tissue  is 
more  likely  to  be  present. 

Both  forms  are  extremely  malignant,  although,  so  long  as 
they  are  contained  in  their  investing  capsules,  they  merely 
push  aside  the  healthy  parts,  but,  so  soon  as  they  rupture 
their  proper  covering,  they  infect  the  neighboring  tissues  for 
a  wide  distance,  not  so  much  by  the  lymphatics  as  by  the 
circulation  ;  and  metastases  are  common,  so  much  so  that 
Gross  found  them  recorded  in  46  per  cent,  of  the  cases 
reported  by  him. 

The  tendency  of  these  tumors  to  suppuration  is  very 
slight,  which  is  a  most  important  matter  in  their  diagnosis, 
and  often  aids  in  distinguishing  them  from  tuberculosis  of 
bone.*  Spontaneous  fracture  may  occur  at  the  seat  of  the 
disease  in  some  cases,  but  not  so  commonly  where  an 
epiphysis  is  affected  as  where  the  growth  is  situated  in  the 
shaft  of  the  bone. 

In  considering  these  growths  as  they  affect  the  hip,  one 
is  surprised  to  see  how  small  a  percentage  of  reported  cases 
have  been  situated  in  the  hip. 

*Gillette,  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  1S76,  ii.  115;  Poinsot,  Bull,  et  Mem.  de 
la  Soc.  de  Chir.,  Paris,  1S77,  iii.  208. 


MALIGNANT    AND    OTHER    TUMORS    OF    THE    HIP  1 73 

Of  70  cases  of  giant-celled  sarcoma,  21  were  in  the  femur, 
and  only  2  of  these  were  in  the  upper  epiphysis,  while  17 
were  in  the  lower  ;  28  cases  affected  the  upper  epiphyses  of 
the  tibia  and  fibula,  giving  in  the  70  cases  2  which  affected 
the  hip,  while  45  were  in  or  about  the  knee  joint. 

Periosteal  sarcomas  do  not  invade  the  joints  in  so  large  a 
proportion  of  cases  as  do  the  central  sarcomas,  of  which  20 
per  cent,  were  found  to  have  affected  the  joint,  while  in  the 
periosteal  variety  only  5  per  cent,  are  so  recorded. 

The  165  cases  analyzed  by  Gross  were  classified  by  him 
as  follows  :  70  were  giant-celled  sarcomas,  45  were  periosteal 
osteoid  sarcomas,  16  were  central  spindle-celled  sarcomas, 
13  were  periosteal  round-celled  sarcomas,  12  were  central 
round-celled  sarcomas,  9  were  periosteal  spindle-celled  sarco- 
mas. 

Central  Sarcomas. 
Giant-celled  Sarcomas. 

Giant-celled  sarcomas  are  also  described  as  myeloid 
tumors  (Paget  *)  and  myelopaxic  tumors  (Nelaton  f).  For- 
merly such  tumors  were  classed  as  spina  ventosa,  cancer  of 
bone,  spleen-like  tumor,  fungus  hematodes,  erectile  tumor  of 
bone,  encephaloid  tumor,  hematoid  tumor,  etc.  This  was 
before  their  true  nature  was  understood. 

The  tumors  are  circumscribed  and  smooth,  although  at 
times  they  may  be  uneven  in  contour.  On  section  the  con- 
sistency is  seen  to  be  much  like  that  of  muscular  tissue,  but 
sometimes  softer.  The  color  is  most  often  reddish  buff  and 
mottled,  while  at  other  times  the  cut  surface  may  be  of  a 
uniform  dark  red.  Fatty  degeneration  gives  a  marbled  ap- 
pearance. Cysts  are  likely  to  form.  They  are  due  to  the 
disintegration  and  liquefaction  of  the  elements  of  the  tumor, 
and  are  filled  with  either  clear  straw-colored  fluid  or  extrav- 

*  Surgical  Pathology,  1853. 

t  D'une  Nouvelle  Espfece  de  Turn.  Benignes  des  Os,  etc.     Paris,  i860. 


174  DISEASES    OF    THE    HIP    JOINT 

asated  and  degenerated  blood.  The  occurrence  of  calcifica- 
tion or  ossification  is  not  nearly  so  common  as  in  periosteal 
growths. 

Microscropic  examination  shows  a  stroma  of  spindle  cells 
and  round  cells,  in  which  are  imbedded  the  characteristic 
giant  cells.  Fatty  elements  and  blood  may  be  present  in 
the  degenerating  cases. 

Other  varieties  of  the  central  sarcoma  are  the  spindle- 
celled  and  the  round-celled. 


Central  Spindle-celled  Sarcoma. 

These  have  been  described  under  the  names  of  fibroplastic 
tumors  (Follin),  recurrent  fibroids  (Paget),  fibronucleated 
tumors  (Bennet),  albuminous  sarcoma  (Gluge),  and  fasicu- 
lated  carcinoma  of  bone  (Miiller). 

There  are  no  cases  on  record  where  they  have  affected  the 
hip. 

Central  Round-cell  Sarcomas. 

These  growths  have  been  described  as  embryoplastic 
tumors  (Lebert),  medulla-celled  tumors  (Nelaton),  granu- 
lation sarcomas  (Billroth),  encephaloid  sarcomas  (Cornil 
and  Ranvier),  juiceless  cancer  (Forster),  medullary  cancer 
(Paget,  Holmes,  etc.),  hematoid  cancer  (Paget),  hsematoma 
of  bone,  etc. 

The  growth  consists  of  spherical  cells,  scarcely  to  be  dis- 
tinguished from  white  blood  corpuscles  in  a  fibrillated  matrix. 
They  are  generally  excessively  vascular,*  and  the  arrange- 
ment is  usually  alveolar.f  Hence  they  resemble  cancer 
structure  very  closely,  which  has  been  the  cause  of  much  con- 
fusion in  their  classification.^ 

*Mercier,  Bull.  Soc.  Anat.  de  Paris,  ii.,  2d  Ser.,  241 ;  Virch.  Archiv,  xxxv.  530;  Bryant, 
Guy's  Hosp.  Rep.,  xx.  358  ;  Poland,  Guy's  Hosp.  Rep.,  xvi.  469 ;  Weil,  Prag.  Viertjhrschft.,  1877, 
iv.  14. 

t  Billroth,  Langenbeck's  Archiv,  xi.  224.  J  Virchow's  Archiv,   iv.  151. 


MALIGNANT    AND    OTHER    TUMORS    OF    THE    HIP  1/5 

It  should  be  borne  in  mind  that  from  their  very  vascular 
structure  they  may  pulsate,  and  simulate  aneurism.  They 
may  also  rupture  internally  or  externally,  and  become  the 
seat  of  extensive  extravasations  of  blood. 

Of  12  cases  collected  by  Gross,  3  were  situated  in  the 
hip.  They  are  the  most  rapidly  growing  of  all  malignant 
tumors  affecting  the  hip. 


Periosteal  Sarcomas. 
Periosteal  Osteoid  Sarcomas. 

The  second  commonest  variety  of  bone  sarcoma  is  espec- 
ially prone  to  attack  the  articular  ends  of  the  long  bones, 
particularly  of  the  femur.  Of  Gross's  45  cases  of  this  vari- 
ety, the  femur  was  affected  in  24. 

This  form  of  malignant  tumor  has  been  described  under 
the  names  of  ossifying  fungus  (Miiller);  malignant  osseous 
tumor  (Stanley),  and  many  of  the  growths  formerly  described 
as  osteoid  cancer  *  are  to  be  included  under  this  affection. f 

These  tumors  consist  of  a  groundwork  of  ossified  tissue, 
surrounded  by  a  hard  or  soft  homogeneous  mass  like  the 
variety  just  described.  The  osseous  tissue  consists  of  plates 
or  spicules  of  bone  radiating  out  from  the  shaft  of  the  bone 
from  which  the  growth  comes.  The  interspaces  are  filled 
out  with  the  sarcomatous  mass.  In  the  great  majority  of 
instances,  the  microscope  shows  the  growth  to  consist 
of  spindle  cells,  while  round-celled  growths  and  mixtures 
of  round  and  spindle   cells   are    also  found. 

Until  a  late  stage  of  the  disease,  the  growth  does  not 
attack  the  bone  proper,  although  in  nearly  half  the  cases 
there  exists  along  with  the  periosteal  tumor  a  sarcomatous 
condition  of  the   marrow,  or  the  spongy  tissue  of  the  epi- 

*Schuh,  Der  Zottenkrebs  und  das  Osteoid,  Mainz,  1852;  Paget,  Surg.  Path.,  1853  ;  Wedl, 
Grundziige  d.  Path.  Hist.,  1854;  Rokitansky,  Wchnblt.  d.  Ztschft.  d.  Wiener  Aerzte,  1857,  i. 

t  Virchow,  Deutsche  Klinik,  1858,  No.  49 :  Volkmann,  Bemerk.  iiber  einige  von  Krebs  zu 
trennende  Geschwiilste,  Halle,  1858. 


1/6  DISEASES    OF    THE    HIP   JOINT 

physis.  It  is  important  to  state  that  in  these  growths  there 
is  no  alveolar  arrangement  of  the  stroma  and  no  included 
epithelioid  cells. 

Other  varieties  of  periosteal  sarcomata  are  the  round- 
celled  and  the  spindle-celled,  the  characteristics  of  which  are 
well  enough  defined  by  their  names.  There  are  no  recorded 
instances  where  either  of  these  varieties  has  been  known  to 
attack  the  hip. 

The  Etiology  of  Sarcoma  of  Bone. 

Bone  sarcomas  occur,  in  most  cases,  before  the  age  of 
thirty  years  (the  average  age  being  twenty-seven).  In  147 
of  Gross's  cases,  where  the  age  was  noted,  it  was  distributed 
as  follows  :  — 

From  10  to  20  years,        45  cases 


From  20  to  30 
From  30  to  40 
From  40  to  50 
From  50  to  60 
From  60  to  70 


55 

26 

II 

7 

3 


Males  are  slightly  more  liable  to  the  affection  than  fe- 
males, 87  out  of  149  cases  being  men. 

Traurnatism  is  the  only  definite  causative  factor  of  which 
anything  is  known.  In  about  half  of  the  cases  some  clearly 
marked  injury  is  to  be  remembered,  which  in  most  cases  is 
clearly  to  be  accounted  the  cause  of  the  affection. 

The  history  of  a  personal  case  of  the  writer's  is  character- 
istic. 

A  little  girl  of  ten,  who  was  in  good  health  to  all  appear- 
ance, while  running  on  a  sidewalk  caught  her  right  foot  in 
the  root  of  a  tree,  and  violently  wrenched  her  right  hip,  being 
thrown  to  the  ground.  She  walked  home,  and  complained 
of  soreness  and  stiffness  there  ;  but  on  that  day  and  the  next 
day  she  was  able  to  walk  about  the  house  with  very  little 
discomfort.  On  the  third  day  the  leg  became  very  painful ; 
and  she  was   under  the  care  of  various   physicians  for    six 


MALIGNANT    AND    OTHER    TUMORS    OF    THE    HIP  1 77 

weeks,  in  which  time  a  purely  expectant  plan  of  treatment 
was  pursued.  Six  weeks  after  the  accident,  when  seen  by 
the  writer,  she  presented  the  appearances  of  acute  hip  dis- 
ease, except  that  the  swelling  was  disproportionate  to  the 
other  symptoms.  Many  months  have  elapsed  since  that 
time,  and  the  thigh  is  now  an  enormous  mass  of  fungus  and 
degenerating  tissue,  which  leaves  no  doubt  as  to  its  malig- 
nant character. 


Treatment  of  Sarcoma  of  the  Hip. 

The  practical  question  that  arises  in  the  treatment  of 
these  malignant  tumors  is  whether  or  not  it  is  worth  while 
to  amputate  the  diseased  leg  at  the  hip  joint,  and  statistics 
are  not  enough  to  settle  the  question.  In  fact,  practically 
all  the  operations  have  been  done  for  tumor  of  the  knee 
joint  or  arm;  but  in  two  cases  of  disease  of  the  humerus,  in- 
volving the  shoulder  joint,  disarticulation  was  done,  and  the 
disease  returned  very  quickly.  The  statistics  of  cases  where 
the  growth  and  all  neighboring  tissues  can  be  removed  by 
operation  have  no  bearing  upon  the  question  of  malignant 
disease  of  the  hip  joint,  because  the  complete  extirpation 
of  the  sarcomatous  growth  is  not  possible. 

On  general  grounds  the  operation  would  be  practically 
hopeless  as  far  as  eradicating  the  disease,  unless  performed 
at  so  early  a  stage  that  the  diagnosis  could  not  be  expected 
to  have  been  made. 

At  the  same  time  a  thorough  operation  at  times  is  likely 
to  afford  relief  in  removing  a  lar-ge,  bleeding,  and  fungous 
mass,  and  allowing  free  drainage  to  the  part  that  remains 
attached  to  the  pelvis.  The  enormous  size  of  the  leg  be- 
comes a  most  distressing  feature  in  these  cases  ;  and  its  re- 
moval, although  attended  by  a  very  serious  risk  of  death  as 
a  result  of  the  operation,  is,  in  some  of  the  most  distressing 
cases,  to  be  considered.  Practically,  however,  very  few 
patients  will  be  found  ready  to  submit  to  so  serious  and  for- 


178  DISEASES    OF    THE    HIP    JOINT 

midable  an  operation,  which  holds  out  practically  no  hope  of 
cure. 

Ca7icer  of  bojie  in  the  modern  pathology  is  exceedingly  rare. 
It  may  begin  either  in  the  periosteum  or  the  marrow,  and 
may  contain  bony  tissue  in  its  meshes.  It  is  accompanied 
by  much  hypertrophy  of  the  periosteum  and  absorption  of 
the  bone  tissue  by  rarefying  ostitis.  To  warrant  the  diagno- 
sis of  cancer,  the  microscopic  structure  should  be  thoroughly 
characteristic. 

Hydatid  cysts  of  the  hip  joint  have  been  described,  and 
they  have  presented  most  of  the  characteristics  of  cold  ab- 
scess. Tapping  and  the  injection  of  iodine  have  sufficed  to 
cure  them.  The  two  cases  in  the  foot-note*  are  such 
hydatid  cysts  of  the  hip  joint. 

Lipomata  of  the  hip  have  been  described  in  the  following 
instances  :  Dupuy,  Bull.  Soc.  Anat.  de  Paris,  1876,  4  s.,  323  ; 
also  Prog.  I\Ied.,  Paris,  1876,  iv.  635  ;  Ferguson,  Lancet, 
London,  1S62,  i.  120;  Pean,  Med.  Prat.,  Paris,  1883,  13;  Za- 
boklicki,  Gaz.  Lek.,  Warszwaza,  1878,  xxv.  33  ;  Wade,  Dub- 
lin Med.  Press,  1843,  ix.  5. 

Cases  of  ^Malignant  Tumors  of  the  Hip. 

Holmes,  Trans.  Med.  Ass'n  South.  N.Y.,  1858-61  ;  Mur- 
ra}',  Br.  AI.  J.,  London,  1865,  ii.  254;  Niese,  Deutsche 
Klinik,  Berlin,  1855  ;  O'Ferrall,  Proc.  Path.  Soc,  Dublin,. 
1840-49,  i.  331;  Santesson,  Hygeia,  Stockholm,  1859, 
trans,  in  Dublin  Med.  Press,  1859,  xliii. ;  Sawyer,  Am.  J. 
Med.  Sci.,  Phila.,  1858,  x.  s.  35,  109;  Awan,  Forh.  Svensk. 
Lak.  Sallsk.  Sammank.,  Stockholm,  1870,  104;  Jeffreys, 
Lancet,  1836,  ii.  429;  Key,  Lancet,  1828,  ii.  508;  McRuer, 
B.  M.  -&  S.  J.,  1854-55,  Ii-  498;  Alalgaigne,  Gaz.  d'Hop., 
Paris,  1846,  viii.  562;  Mears,  Med.  News,  1884,  xlv.  752; 
Smith,  j\Ied.  Exam.,  London,  1877,  ii.  566;  Taramelli,  Ann. 
L^niv.  di  Med.,  Milano,  1827,  xlii.  295  ;  Tansini,  Gaz.  Med. 
Ital.  Lomb.,  Milano,  1886,  xlvi.  ;  Baralz,  Berl.  Klin.  Wchsft., 
1887,  xxiv.  610. 

*Abeille,  Gaz.  Med.  de  Paris,  1S72,  xx™.  420;  Bourdy,  Bull.  Soc.  de  Med.  de  la  Sarthe,  1875, 
33- 


LOOSE    BODIES    OF    THE    HIP    JOINT  1/9 


Chapter    XT. 
LOOSE    BODIES    OF    THE    HIP   JOINT. 

The  possibility  of  the  occurrence  of  this  affection  makes 
its  consideration  necessary,  but  the  affection  is  of  such 
rarity  that  the  section  need  be  only  a  brief  one.  Loose 
bodies  are  nearly  always  found  in  the  knee  joint;  but 
the  hip,  elbow,  and  other  joints  are  not  to  be  considered 
exempt.* 

Such  loose  bodies  are  also  called  loose  cartilages,  joint 
mice,  rice  bodies,  floating  bodies,  corpora  libera  articulorum, 
etc. 

In  structure  they  are  either  to  be  described  as  fibroma- 
tous,  lipomatous,  or  chondromatous,  according  to  the  struct- 
ure found  on  section. 

They  are  formed  in  one  of  the  following  ways  :  — 

{a)  As  the  fibrous  residue  of  an  exudation. 

{b)  As  residue  from  a  blood  clot.  This  was  Hunter's 
idea  of  the  cause  of  most  loose  bodies;  but  proof  that  they 
may  exist  as  the  outcome  of  a  simple  effusion  of  blood  is 
still  wanting,  although  the  possibility  of  free  bodies  from 
this  source  is  recognized  in  every  modern  classification. 

{c)  Broken  off  osteophytes  in  arthritis  deformans. 

{d)  Hypertrophied  or  degenerated  portions  of  the  synovial 
fringes,  as  seen  in  chronic  synovitis  and  arthritis  deformans. 

(e)  Marginal  ecchondroses,  as  seen  in  arthritis  deformans, 
which  have  grown  into  the  joint  and  have  been  broken  off. 

(/)  Foreign  bodies,  such  as  bullets  and  needles,  which 
have  penetrated  into  the  joint  cavity  and  perhaps  have 
become  encapsulated. 

*  Howard  Marsh,  in  Treves'  Surg.,  vol.  ii.  p.  250;  Konig,  Arch.  f.  Klin.  Chir.,  1888. 


l80  DISEASES    OF    THE    HIP    JOINT 

(£■)  Bits  of  cartilage  or  bone  chipped  off  by  accident,  or 
more  often  loosened  by  a  degenerative  process  set  up  by 
the  accident.*  It  has  been  clearly  proved  that  such  bodies 
can  be  formed  in  consequence  of  a  wrench  or  fall.f  They 
seem  capable  of  independent  growth  |  as  well  as  of  calcifi- 
cation. 

These  bodies  may  exist  free  in  the  joint,  or  they  may  be 
pedunculated  and  attached  to  the  mucous  membrane.  In 
size  they  vary  from  that  of  a  pin-head  to  that  of  a  horse- 
chestnut,  so  far  as  the  knee  is  concerned,  where  they  have 
been  chiefly  studied. 

It  will  be  seen  that  they  exist  most  often  in  connection 
with  some  synovial  affection,  generally  arthritis  deformans. 
Traumatism  would  be  much  less  likely  to  be  a  cause  of 
loose    bodies    in    the   hip    than   in   the   knee. 

The  treatment  of  loose  bodies  of  the  hip  can  be  settled 
very  briefly.  No  measure  short  of  their  excision  would  offer 
any  prospect  of  relief.  Consequently,  in  the  event  of  such 
a  diagnosis  having  been  made,  the  question  which  arises  is 
the  delicate  one  of  undertaking  so  extensive  an  operation  as 
incision  of  the  hip  for  the  removal  of  the  loose  body. 

Under  exceptional  circumstances,  this  might  be  justified; 
but,  in  general,  the  treatment  would  best  consist  of  pallia- 
tive measures.  Two  cases  are  reported  by  Konig  where 
an  operation  was  successful  in  removing  what  was  practi- 
cally a  foreign  body,  being  the  entire  cartilage  of  the  femur 
cast  off  by  an  osteochondritis,  and  lying  loose  in  the  hip 
joint,  where  it  gave  rise  to  the  classical  symptoms  of  a  for- 
eign body. 

*Brodhurst,  St.  Geo.  Hosp.  Rep.,  1867,  ii.  141;  Deutsch.  Klinik,  Volkmann,  1867,  No.  48; 
Virchow,  Die  Krankhaften  Geschwiilste,  Berlin,  1863. 

t  Marsh,  Brit.  Med.  Journal,  April  14,  1888;  Shattock,  Path.  Soc.  Trans.,  xv.  206. 
+  Recklinghausen,  De  Corp.  Lib.  Artie,  1864. 


LOOSE    BODIES    OF    THE    HIP    JOINT  l8l 


Foreign  Bodies  of  the  Hip  Joint. 

Afanasjev,  Ejened,  Klin.  Gaz.,  St.  Petersburg,  1882,  ii. 
{formation  of  a  large  number  of  loose  bodies);  Beraud, 
Compte  Rend,  de  la  Soc.  de  Biol,  1852,  iii.  27;  Erchmann, 
Journ.  d.  Chir.  und  Augenk'h'de,  1883,  xix.  120;  Wagstaffe, 
Trans.  Path.  Soc,  London,  1872-73,  xiv.  192. 


l82  DISEASES    OF    THE    HIP    JOINT 


Chapter  XII. 

CONGENITAL    DISLOCATION    OF    THE    HIP 
JOINT. 

Etiology. 

Congenital  dislocation  of  the  hip  is  not  an  affection 
which  is  at  all  common  ;  nor,  on  the  other  hand,  should  it 
be  spoken  of  as  a  very  great  rarity.  In  3,100  cases  of  surgi- 
cal disease  in  children  applying  at  the  Boston  Children's 
Hospital  there  were  only  24  cases  of  congenital  hip  disloca- 
tion, *  or  a  little  less  than  one  in  a  hundred  cases  of  surgical 
disease.  Chaussier  f  found  only  one  case  of  congenital  dis- 
location of  the  hip  in  23,293  children  born  at  the  Paris 
Maternite ;  but  Parise,|  who  dissected  the  hip  joints  of  332 
children  dying  at  the  Hopital  des  Enfants  Trouves,  found 
3  congenital  dislocations.  But  any  attempt  at  picturing  the 
frequency  of  the  disease  by  statistics  must  needs  be  unsatis- 
factory. The  frequency  of  cases  in  the  streets  of  any  city 
must  show  to  the  careful  observer  that  the  affection  is  more 
common  than  is  generally  believed. 

Sex.-"— For  some  unexplained  reason  it  affects  girls  much 
more  often  than  boys,  as  will  be  seen  from  the  following 
table,  which  includes  all  large  groups  of  reported  cases  :  — 

*  Bradford  and  Lovett,  ioc.  cit.  t  Chaussier,  Deutsch.  Chirurgie,  26,  p.  83. 

%  Parise,  Bull,  de  la  Soc.  de  Chir.,  1866,  vii.  331. 


lO 

67 

II 

96 

H 

1(^ 

2 

23 

O 

24 

3 

JJ 

40 

301 

CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  1 83 

Reporter.  Number.  Boys.  Girls. 

Drachman,* 77 

Pravaz, 107 

Kronlein, 90 

N.Y.  Orth.  Hosp.,t     ....  25 

Boston  Ch.  Hosp  ,f    ....  24 

Prahl4 _i8 

341 

Location. —  The  affection  is  more  often  single  than  double, 
and  affects  the  right  and  left  hip  in  practically  the  same 
number  of  cases. 

Of  313  cases,  122  were  double,  and  191  single.  Of  these^ 
95  affected  the  right  hip,  and  96  the  left. 

Connection  with  Other  Deformities. —  Occasionally  disloca- 
tion of  the  hip  exists  in  connection  with  other  deformities^ 
such  as  congenital  valgus,  anencephalia,  hare-lip,  and  the 
like;  but,  for  the  most  part,  it  occurs  in  well-formed  and 
healthy  children,  and  in  this  respect  it  differs  from  other 
congenital  dislocations,  as  well  as  in  its  greater  frequency. 

The  theoretical  discussion  of  the  etiology  is  capable  of 
prolongation  to  any  extent.  There  are  a  few  settled  fa'cts 
which  should  be  reviewed  before  going  on  to  the  intricate 
theories  which  strive  to  account  for  this  remarkable  con- 
dition. 

Girls  are  very  much  more  often  affected  than  boys. 

The  affection  is  more  often  single  than  double. 

The  affection  is  in  some  cases  hereditary  (Dupuytren,§ 
Bouvier,  II  Stadtfeldt,  Verneuil,^  and  Volkmann  **). 

To  pass  now  to  the  purely  theoretical  considerations  which 
have  been  advanced,  one  finds  a  series  reaching  from  the 
time  of  Hippocrates  (who  believed  the  dislocation  to  be  due 
to  injuries  or  uterine  pressure)  to  the  present  day,  when  the 

*Drachmann,  Schmidt's  Jahrbuch,  1881,  p.  170.  t  Bradford  and  Lovett  from  reports. 

%  Cent.  f.  Chir.,  1881,  p.  57.  §  Lecons  Orales  de  Clin.  Chir.,  Paris,  1832,  vol.iii. 

il  Lefon  Clin,  sur  les  Mai.  de  I'Appareil  Locomoteur.    ITGaz.  desHop.,  1886,  68. 
**  Volkmann,  K'h'ten  der  Bewegungsorgane. 


184  DISEASES    OF    THE    HIP    JOINT 

theory  of  non-development  has  established  itself,  and  is 
accepted  as   the  probable  explanation  of  the  condition. 

It  will  hardly  be  worth  while  to  do  more  than  to  pass  in 
review  the  other  theories,  and  this  can  be  done  most  clearly 
and  easily  by  following  Kronlein's*  most  admirable  classifi- 
cation, 

1.  The  so-called  dislocation  is  traumatic,  and  is  caused  :  — 
{a)  By  external   forces    acting  upon  the  foetus,  or  by  its 

own  muscular  contractions.  Chaussier  quotes,  in  support  of 
this  theory,  a  case  where  a  woman,  nine  months'  pregnant, 
felt  such  violent  foetal  movements  on  three  occasions  that 
she  became  unconscious,  and  was  delivered  of  a  child  with 
dislocation  of  the  forearm.  Chatelain,  Kleeburg,  and  Ziele- 
wicz  attributed  three  cases  to  a  fall  in  the  seventh  month. 

{b)  By  injury  during  delivery. 

It  is  possible  to  see  how  in  some  cases  traction  in  the 
groin,  during  breech  deliveries,  might  cause  dislocation, 
especially  where  the  hip  ligaments  are  weak.  The  propor- 
tion of  breech  deliveries  in  these  cases  is  abnormally  large, 
as  is  well  known,  Adams  reporting  7  breech  presentations 
in  45  cases. 

2.  The  so-called  dislocation  is  spontaneous,  and  is  caused 
{a)  by  softening  and  laxity  of  the  ligaments  (Sedillot),  (b) 
by  foetal  hydrarthrosis  (Parise),  fungous  synovitis,  and  effu- 
sion (Verneuil  and  Broca),  or  destructive  disease  of  the  bone 
(Morel,  Lavallee,  Albers,  Von  Ammon,  Guerin). 

3.  The  so-called  dislocation  is  due  to  the  peculiar  position 
of  the  lower  limbs  of  the  foetus  in  utero. 

{a)  This  may  be  strong  flexion,  causing  pressure  on  the 
lower  and  posterior  part  of  the  capsule  (Dupuytren). 

{b)  Strong  adduction  may  be  induced  by  a  compression 
by  the  uterine  walls,  due  to  deficiency  of  the  amniotic  fluid 
(Roser). 

4.  The  so-called  dislocation  is  due  to  primary  muscular 
contraction  (like  the  deformities  of  club  foot,  wry  neck,  and 

*  Deutsche  Chir.,  Lief.  26,  p.  82. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT  l8$ 

scoliosis)  ;  and  this  is  to  be  regarded  as  evidence  of  an  affec- 
tion of  the  central  nervous  system.  This  theory  has  had 
many  supporters,  among  whom  may  be  mentioned  Jules 
Guerin,  Chaussier,  Melicher,  Mercer,  Adam,  and  Carnochan. 

It  may  be  said  in  regard  to  this  theory  that  the  analogous 
deformities  from  which  the  theory  was  derived  are  not  now 
regarded  as  the  results  of  primary  muscular  contraction  by 
most  modern  orthopedists.  Club  foot,  at  least,  is  regarded 
rather  as  an  expression  of  retarded  foetal  development. 

5.  The  so-called  dislocation  is  often  the  last  stage  of 
a  paralysis  and  atrophy  of  the  peritrochanteric  muscles 
(Verneuil,  Reclus,*  and  Dalby) ;  and  iliac  dislocation  is  the 
most  common  form,  because  of  the  paralysis  of  the  gluteal 
and  pelvitrochanteric  muscles  and  the  integrity  of  the  ad- 
ductor  group. 

Such  theories  as  these  need  little  refutation.  They  were 
devised  in  the  absence  of  any  satisfactory  theory,  and  rest, 
for  the  most  part,  on  a  purely  fanciful  basis.  They  explain 
nothing  for  the  most  part,  and  can  only  be  accepted  as 
explaining  an  occasional  case.  Cases  which  are  caused  by 
traumatism  at  birth  undoubtedly  occur ;  but  they  are  not, 
strictly  speaking,  congenital.  The  causation  of  dislocation 
by  external  violence  to  the  "mother  rests  on  a  very  slender 
basis.  In  the  same  way  it  may  be  said  of  the  other  theories 
that  it  is  perfectly  possible  that  they  may  account  for  an 
occasional  case,  but  that  good  evidence  is,  for  the  most  part, 
wanting.  Destructive  bone  disease  in  the  foetus  is  very 
rare ;  but  one  cannot  say  that  it  is  not  the  occasional  cause 
of  a  congenital  dislocation,  especially  since  the  acute  arthri- 
tis of  infants  produces  a  condition  at  the  hip  almost  indis- 
tinguishable from  congenital  dislocation. 

In  general,  however,  it  should  be  said  that  the  interest  of 
these  theories  is  chiefly  historical,  and  that  most  cases  are 
to  be  considered  as  coming  under  the  head  of  the  theory 

*Rev.  Mens,  de  M^d.  et  de  Chir.,  1878,  p.  88. 


1 86  DISEASES    OF    THE    HIP    JOINT 

of  retarded  development  about  to  be  considered,  which  has 
received  the  sanction  of  nearly  all  modern  authority. 

6.  The  so-called  dislocation  is  in  most  cases  due  to  an  ar- 
rest or  defect  of  development.  A  theory  of  this  nature  was 
first  advanced  by  Paletta,  and  taken  up  by  Breschet,  Dupuy- 
tren,  and  Schreger.  Von  Ammon  *  elaborated  it  still  more 
fully,  and  the  theory  often  goes  by  his  name.  It  was,  how- 
ever, Grawitz  f  who  put  the  theory  on  a  sound  scientific 
basis;  and  it  seems  more  just  that  it  should  be  known  by  his 
name,  if  it  is  desirable  that  any  person's  name  should  be 
given  to  the  theory  which  is  the  outcome  of  the  writings  of 
so  many. 

According  to  X'on  Ammon,  this  affection  cannot  properly 
be  called  a  dislocation.  He  would  class  these  cases  as 
"dysarthroses  congenitae,"  and  he  says  in  defence  of  this 
position :  "  In  many  cases  there  is  in  part  the  greatest  cer- 
tainty and  in  part  the  greatest  probability  that  the  affection 
depends  upon  an  arrest  of  development  of  the  constituent 
parts  of  the  joint.  ...  If  the  term  'luxatio'  is,  in  general, 
understood  to  mean  the  slipping  of  a  movable  bone  out  of 
its  natural  joint  connections,  it  is  applicable  only  with  the 
greatest  restrictions  to  the  congenital  dislocation  in  ques- 
tion." 

The  fault  seems  to  lie  in  the  failure  of  the  Y-cartilage  at 
the  bottom  of  the  acetabulum  to  carry  on  the  growth  of  the 
three  segments  of  the  acetabulum.  Dollinger  believed  that 
this  defect  was  due  to  a  premature  ossification  ;  while  Grawitz, 
from  the  examination  of  12  specimens  in  7  new-born  chil- 
dren, seems  to  have  proved  that  it  is  rather  an  arrest  of  de- 
velopment. For  instance,  in  one  case  the  acetabulum  was 
only  as"  large  as  that  of  a  foetus  of  five  months,  and  the  carti- 
lage was  abnormally  broad  even  then  because  of  delayed  ossifi- 
cation. The  formative  zone  in  each  epiphysis  on  microscopic 
examination  was  seen  to  be  very  imperfect,  with  cells  widely 

*  Von  Ammon,  Die  Angeborene  Chir.  K'h'ten  des  Menschen,  1842,  ix. 
t  Virchow's  Archiv,  1S78,  vol.  bociv.  p.  i. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT  1 8/ 

separated  and  scanty ;  while  in  two  other  cases  the  zone  of 
calcification  was  wanting,  and  the  cartilage  cells  contained 
no  nuclei  and  only  fat  granules.  In  no  case  was  there  any 
evidence  of  premature  ossification. 

The  femur  in  these  cases  seemed  to  have  reached  a  com- 
paratively normal  size,  and  in  this  disproportion  lies  the 
secret  of  the  deformity.  The  head  of  the  femur  is  too  large 
to  enter  the  shallow  and  constricted  acetabulum,  and  lies  out- 
side of  it,  not  dislocated,  but  never  having  been  in  the  proper 
relation  with  it. 

Although,  as  has  been  already  stated,  this  theory  cannot 
be  held  accountable  for  all  cases,  the  whole  weight  of  modern 
authority  regards  it  as  the  most  acceptable  and  most  scien- 
tific of  all  the  theories  which  would  explain  the  cause  of  the 
deformity. 

One  merit  of  this  theory  is  to  be  found  in  the  fact  that  it 
makes  congenital  dislocation  analogous  with  other  deformities, 
inasmuch  as  it  finds  its  causation  in  a  retarded  development, 
as  is  the  case  in  hare-lip,  cleft  palate,  and  other  deformities. 
The  fact  that  congenital  dislocation  occurs,  in  a  certain  pro- 
portion of  instances,  in  connection  with  these  deformities, 
also  lends  weight  to  this  view.  Numerically,  females  are 
more  liable  to  deformity  of  all  sorts  than  are  males ;  and,  con- 
sequently, this  theory  gives  a  certain  sort  of  explanation  of 
the  great  preponderance  of  females  among  those  affected  by 
congenital  dislocation  of  the  hip.  At  the  same  time  it  is  far 
from  a  satisfactory  explanation  of  this  overwhelming  propor- 
tion. 

-  The  conclusion  of  the  whole  matter  cannot  be  stated 
better  than  has  been  done  by  Stimson,  who  says  that,  while 
"a  limited  number  of  cases  of  dislocations  existing  at  birth, 
especially  in  joints  other  than  the  hip,  may  have  been  caused 
by  traumatism,  abnormal  position  of  the  limb,  or  paralysis, 
in  the  manner  alleged  by  various  writers,  yet,  in  the  great 
majority  of  congenital  dislocations  of  the  hip,  the  cause  is  to 
be  found  exclusively  in  an  arrest  of  development  of  the  ace- 


l88  DISEASES    OF    THE    HIP    JOINT 

tabulum  by  deficient  action  or  vitality  of  the  cells  of  the  Y- 
cartilage." 

In  conclusion,  it  may  be  permissible  to  call  attention  once 
more  to  the  fact  that  dislocations  occurring  during  birth 
are  not  to  be  classed  as  congenital,  but  as  traumatic ;  and, 
although  they  are  undoubtedly  in  the  minority,  still  they 
should  be  recognized  as  a  special  class  of  hip  dislocations,  to 
be  in  some  cases  distinguished  practically  from  congenital 
dislocations. 

Pathology. 

In  discussing  pathological  changes  found  in  connection 
with  congenital  dislocation  of  the  hip,  it  should  be  remem- 
bered, as  has  been  pointed  out  by  Gurlt,  that  there  should 
be  distinguished  two  kinds  of  changes, —  those  due  to  the 
affection  itself,  and  those  changes  produced  by  weight  bear- 
ing upon  the  affected  limb,  which  latter  changes  are  super- 
added to  those  of  the  disease  itself. 

Autopsies  on  cases  which  have  not  walked  are  rare,  and 
most  of  the  pathology  has  been  learned  from  the  examina- 
tion of  cases  which  have  borne  weight  on  the  limbs.  Early 
autopsies  have  been  reported  by  Mercer,  Adams,*  Parise,t 
Dollinger ;  J  and  the  seven  cases  of  Grawitz  §  are  the  most 
important  of  all,  as  well  as  the  case  of  Verneuil.  || 

In  the  vast  majority  of  cases,  the  head  of  the  bone  is  found 
upon  the  dorsum  of  the  ilium,  resting  either  upon  the  iliac 
bone  itself  or  upon  the  gluteus  minimus  muscle.  Cases,  how- 
ever, have  been  reported  where  the  head  of  the  femur  was 
dislocated  on  to  the  pubis  and  into  the  obturator  foramen. 
They  are,  however,  extremely  rare.  It  should  be  borne  in 
mind  that  the  femur  and  the  acetabulum  are  developed  in  the 
embryo  from  one  continuous  tissue,  and  that,  although  at 
first  they  are  for  this  reason  necessarily  in  contact  with  each 
other,    when    the  development  of   the  acetabulum  becomes 

*  Journal  Edinb.  Phys.  Soc,  1853.  t  Quoted  by  M.  Adams. 

t  Virchow,  Archiv.  §  Arch.  f.  P.  Anat.,  Ixxiv.         ||  Gaz.  des  Hop.,  1852,  530. 


CONGENITAL    DISLOCATION    OF    THE    HIP  1 89 

retarded  and  the  growth  of  the  femur  goes  on  normally,  it  is 
impossible  for  the  normal  relation  to  be  maintained  indefi- 
nitely. Consequently,  even  before  weight  is  borne  upon  the 
limb,  the  head  of  the  femur  is  drawn  upward  and  backward, 
resulting  in  a  distortion  of  the  capsule  and  the  formation  of 
a  new  articular  surface,  where  the  head  of  the  femur  finally 
rests.  So  that,  added  to  the  naturally  imperfect  growth  of 
the  acetabulum,  comes  a  still  further  element  of  disturbance 
in  the  fact  that  the  femur  is  not  in  contact  with  it,  as  it 
should  be,  during  its  period  of  active  growth. 

To  consider  the  changes  as  they  have  been  found  in  the 
cases  reported,  one  comes  first  to  the  acetabulum.  In  no 
reported  case  has  this  been  entirely  absent ;  and,  on  the 
other  hand,  rarely  has  it  been  reported  as  normal.  In 
general,  it  is  found  smaller  and  more  shallow  than  normal, 
often  being  changed  into  the  shape  of  a  flattened  oval, 
a  change  due  to  the  altered  position  of  the  femur.  Some- 
times the  new  acetabulum  is  continuous  with  the  old  one, 
while  at  other  times  the  two  form  distinct  cavities.  In 
cases  which  have  not  walked,  the  new  acetabulum  is  not  an 
important  feature.  In  the  case  of  Paletta,  three  distinct  de- 
pressions had  been  made  by  the  head  of  the  femur.  In  cases 
which  have  walked,  and  especially  in  cases  where  the  de- 
formity is  comparatively  little  disabling,  one  finds  a  rough 
elevated  border  of  bone,  consisting  of  osteophytes  deposited 
upon  the  upper  border  of  the  elongated  oval,  which  is  merely 
nature's  effort  to  strengthen  this  new  socket,  and  to  protect, 
so  far  as  may  be,  the  head  of  the  femur  from  slipping  up- 
ward. The  cartilaginous  rim  of  the  acetabulum  is  often 
wanting.  Sometimes  exostoses  develop  in  the  acetabulum 
itself  (Porto). 

The  femur  shows  changes  that  are  less  marked,  but  at 
the  same  time  distinctive.  The  head  of  the  femur  in  the 
reported  dissections  may  be  normal,  or  the  head  and  neck 
may  be  entirely  wanting.  Intermediate  conditions  are 
found  in  all  degrees.     As  a  rule,  the  neck  is  shorter  than 


IQO  DISEASES    OF    THE    HIP   JOINT 

normal,  and  is  more  at  a  right  angle  to  the  shaft  than  is 
commonly  found. 

Perhaps  some  of  the  most  important  changes  are  to  be 
found  in  the  capsule  of  the  joint,  which  is  much  hyperlro- 
phied,  and  thickened  and  stretched.  It  may  be  constricted 
at  its  centre  into  an  hour-glass  form.  In  cases  which  have 
walked,  the  hypertrophy  is  the  result  of  its  new  function  ;  for, 
in  most  cases  of  bad  congenital  dislocation,  the  body  is  hung 
upon  the  femur  by  means  of  the  capsule  of  the  hip  joints,  in 
the  same  way,  as  Volkmann  has  pointed  out,  that  an  old- 
fashioned  stage-coach  was  hung  upon  its  leather  springs. 
The  head  of  the  femur  plays  loosely  against  the  dorsum  of 
the  ilium,  and  is  retained  by  a  bony  socket.  The  onl)"  thing 
that  keeps  the  head  of  the  femur  from  slipping  up  indefi- 
nitely is  the  capsule  of  the  hip  joint,  which  runs  from  the 
rim  of  the  acetabulum  to  the  head  of  the  femur.  Conse- 
quently, it  forms,  perhaps,  the  most  important  part  of  the 
congenitally  dislocated  joint.  Although  the  capsule  is 
usually  entire  originally,  the  wearing  upon  it  of  the  head  of 
the  femur  may  cause  wearing  away  over  the  new  acetabulum. 

The  synovial  surface  of  the  capsule- is  usually  smooth  and 
moist,  and  of  normal  appearance  ;  but  attachments  to  the  rim 
of  the  acetabulum  from  which  the  capsule  is  stretched,  as 
well  as  to  the  head  and  neck  of  the  femur,  are  common. 
The  synovia  varies  in  amount,  sometimes  being  normal  and 
sometimes  excessive.  The  capsule,  which  is  especially 
thickened  in  that  part  corresponding  to  the  Y-ligament,  is 
sometimes  attached  to  the  fascia  of  the  gluteal  muscles  ;  and 
the  hour-glass  constriction,  already  alluded  to,  is  an  impor- 
tant factor  in  preventing  apposition  of  the  head  of  the  femur 
and  the  acetabulum. 

In  -cases  of  long  standing,  that  part  of  the  capsule  which 
lies  between  the  head  of  the  femur  and  the  new  socket  is 
liable  to  be  worn  out  by  the  constant  rubbing  and  to  dis- 
appear. In  this  case,  the  capsule  appears  to  be  attached  to 
the  rim  of  the  new  acetabulum.     This,  however,  may  not  be 


CONGENITAL    DISLOCATION    OF    THE    HIP  191 

the  case ;  and  the  capsule,  along  with  the  pelvitrochanteric 
muscles,  and  even  the  psoas  and  iliacus  at,  times,  serves  only 
as  a  tough  suspensory  ligament.     In  the  case  first  mentioned. 


Fig.  50.— UNILATERAL   CONGENITAL   DISLOCATION    OF    THE    LEFT    LEG,    SHOWING    THE 
NATURAL   POSITION    IN   STANDING. 

the  capsule  is  fused  with  the  periosteum  of  the  ilium,  and  is 
adherent  all  around  the  periphery  of  the  new  socket. 

Inasmuch  as  the  pelvis  is  suspended  by  the  capsular  liga- 
ment, it  is  a  matter  of  some  practical  importance  whether 


192  DISEASES    OF    THE    HIP    JOIXT 

the  new  acetabulum  forms  directl}^  over  the  old  one  or  above 
and  behind  it.  If  it  forms  direct! v  over  the  old  one,  the  pel- 
vis   remains  in   practically  the  normal   plane.      If,  however, 


Fig.  51. —  THE   SAME   CASE    Ar^    IX    FIG.    fO.      SHOWING   THE   CORRECTED    POSITION. 

the  new  socket  develops  posteriorly,  the  angle  of  the  pelvis 
is  of  course  changed,  and  it  is  tilted  forward  on  a  transverse 
axis,  occasioning  some  lordosis  in  the  back.  This  patho- 
logical condition  is  probably  the  explanation  of  the  varying 
amount  of  distortion  which  is  noticed  clinicallv. 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT 


193 


Suspended  in  this  way,  one  would  suspect  that  the  devel- 
opment and  growth  of  the  pelvis  would  be  abnormal  ;  and 
such  is  the  case.  The  crests  of  the  ilia  come  nearer  each 
other :  while  the  tuberosities  of  the  ischia  are  separated,  so 
that  the  upper  part  of  the  pelvis  is  constricted,  while  the 
lower  part  is  elongated.  In  addition  to  this,  the  sacrum  is 
more  curved  than  it  normally  should  be. 

The  condition  of  the  lig- 
amentum  teres  varies 
within  wide  limits.  In  the 
infant  it  may  be  fused  with 
the  capsule,  but  it  is  never 
entirely  wanting  (Kron- 
lein),  although  it  may  be 
represented  only  by  a  very 
small  thread.  In  the  case 
of  persons  who  have 
walked  it  may  be  wanting 
(Bowlby,  Coudray,  etc.). 
Most  commonly  it  is  elon- 
gated and  thickened,  ap- 
parently aiding  in  the  sus- 
pension of  the  pelvis  from 
the  femora.  Again  it  is 
subjected  to  all  sorts  of 
irregularities,  sometimes 
rising  by  two  heads  from 
the  acetabulum,  and  vary- 
ing in  many  other  ways 
from  the  normal  condition. 
It  is  not  an  important  fac- 
tor in  the  pathology.  The 
muscles  around  the  hip 
joint  are  modified    chiefly 

in  a  mechanical  way,   as  must  evidently  be  the  case  from 
the  distortion  of  the  parts   involved.     The  gluteal  muscles 


Fig.  52. —  DOUBLE  CONGENITAL  DISLOCATION 
OF  A  SEVERE  GRADE,  SHOWING  THE  LORDOSIS  OF 
THE  BACK  AND  THE  PROMINENCE  OF  THE  TRO- 
CHANTERS. 


194 


DISEASES    OF    THE    HIP    JOINT 


are  contracted  ;  and  the  muscles  inserted  around  the  neck 
of  the  femur  are  of  course,  for  the  most  part,  stretched  and 
atrophied,  as  is  also  the  case  in  the  other  muscles  which 


Fig.   53- — DOUBLE    COXGEXITAL    DISLOCATION    OF    A    MILD   GRADE,    SHOWING    LESS 
LORDOSIS    AND    BLT    LITTLE     DEFORMITY. 


are  not  brought  into  activity  in  the  new  position  assumed  by 
the  femur. 

Fatty  or  fibrous  degeneration  of  the  disused  muscles  is  not 

uncommon  fKronlein,  Bardeleben). 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT 


195 


Treatment. 

The  treatment  of  congenital  dislocation  of  the  hip  has 
never  been  regarded  as  a  credit  to  surgery.  For  the  most 
part,  the  deformity  has  been  regarded  as  irremediable,  and 
surgeons  have  been  slow  to  advise  either  operative  or  me- 
chanical treatment.  Before  the  advent  of  antiseptic  surgery 
operation  was,  of  course,  not  to  be  advised ;  and  the  results 
of  mechanical  treatment  have  been  such  that  there  was  little 
to  be  said  in  favor  of  that. 


Treatment  by  Extension  and  Apparatus. 

The  latest  method  of 
this  form  of  treatment  is 
that  by  continuous  exten- 
sion, made  most  often  by 
a  weight  and  pulley  while 
the  patient  is  confined  in 
bed.  Pravaz,  senior,* 
claimed  to  have  cured  a 
case  by  this  method,  and  a 
committee  was  appointed 
from  the  French  Academy 
of  Medicine,  which  should 
investigate  the  claims  ad- 
vanced by  the  surgeon. 
This  committee  disagreed 
as  to  the  cure,  but  consid- 
ered that  the  patient  was 
much  benefited.  Pravaz, 
junior,  claimed  a  similar  re- 
sult some  years  later  in  a 
patient  whom  he  exhibited. 
A  committee  from  the  So- 
ciety   of     Surgery  f     was 

*  Bull,  de  I'Acad.  de  Med.,  Paris,  vol.  iii.  p 


Fig.    54. —  SIDi;    \IE\V    Ol-     A     MILD    CA.sl:,     SHOW- 
ING  THE   CHARACTERISTIC    ATTITUDE. 


t  Bull,  de  la  Soc.  de  Chir.,  1864,  218. 


196 


DISEASES    OF    THE    HIP   JOINT 


again  appointed  to  examine  the  case,  but  was  of  the  opin- 
ion that,  although  much  benefit  had  resulted,  a  reduction  of 
the  dislocation  had  not  occurred.  This  is  not  surprising  in 
the  light  of  the  modern  view,  which  would  regard  the  so- 
called  dislocation  as  a  malformation  rather  than  a  true  dis- 
location.    With  an  imperfect  acetabulum  and  the  head  of  the 

femur  too  large  to   enter 
it,  it  is  not  surprising  that 
so    many    surgeons    have 
failed  to  cure  the  deform- 
ity by  extension,  however 
prolonged.     A  similar  re- 
sult  was    reached    in    the 
case  of  Guerin,  who  also 
treated  cases   by  continu- 
ous extension.     The  com- 
mittee reported  that  two 
centimetres    had     been 
gained   in    one    case,    but 
that  in  this  case,  also,   it 
could  not  be  claimed  that 
the    dislocation    was    re- 
duced.    Mr.  William   Ad- 
ams *    has     recently     re- 
ported satisfactory  results 
in  the  treatment  of  hip  dis- 
location by  the  method  of 
extension.     In  four  cases, 
two  unilateral  and  two  bi- 
lateral, he  reports  that  the 
head  of  the  femur  seems 
to  be  retained  in  its  proper  place  in  each  case.     Inasmuch 
as  only  two  years  and  seven  months  have  elapsed  since  the 
beginning  of  treatment,  it  seems  hardly  fair  to  consider  the 
cases  of  Mr.  Adams  as  more  than  very  doubtful  results. 


Fig.  55  — FRONT  VIE"\V  OF  A  DOUBLE  Dl-LL"  A- 
TION-  OF  MODERATE  SEVERITY,  SHOWING  THE 
CHARACTERISTIC  ATTITUDE  IN  STANDING,  AS 
WELL   AS   THE    BROADENING   OF    THE    PERINEUM. 


*  British  iMed.  Journal,  1890. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT 


197 


The  classical  case  that  gives  hope  that  extension  may 
often  be  regarded  as  a  cure  for  this  distressing  deformity 
is  the  one  reported  by  Dr.  Buckminster  Brown,  of  Boston,  in 
1885.* 

A  girl  four  years  old  had  double  congenital  dislocation  of 
the  hip.  The  joints  were  loose,  the  walk  was  very  bad,  and 
no  trace  of  an  acetabu- 
lum could  be  found  on 
manipulation.  The  pa- 
tient was  put  to  bed,  and 
traction  was  made  by 
weights  which  had  for 
their  object  the  stretch- 
ing of  the  contracted 
tissues  and  the  bring^inp: 
of  the  femur  into  its 
proper  position.  After 
some  weeks,  passive 
movements  were  made 
by  changing  the  posi- 
tion of  the  pulleys.  For 
thirteen  months  the 
child  was  kept  in  bed 
recumbent,  and  then  she 
was  encouraged  to  make 
the  movements  of  walk- 
ing without  bearing- 
weight  on  the  legs. 
This  was  accomplished 
by  the  wheel  crutch. 
About  two  years  and 
three   months  after  the 

beginning  of  treatment  the  heads  of  the  femora  were  found 
in  place  on  Nekton's  line,  and  the  child  was  allowed  to 
walk  gradually ;    and  at  the  time  of  Dr.  Brown's  report  the 


Fig.  56. —  FRONT  VIEW  OF  A  VERY  SEVERE  CASE 
OF  DOUBLE  DISLOCATION  WHERE  FLEXION  OF  THE 
LEGS  WAS  PRESENT  AND  WALKING  WAS  ALMOST 
IMPOSSIBLE.  THE  LORDOSIS  IN  THIS  CASE  WAS  EX- 
CESSIVE. 


*  Boston  Med.  and  Surg.  Journal,  1885,  No.  23. 


iqS  diseases  of  the  hip  joint 

walk  was  normal,  and  she  was  able  to  play  and  run  about  like 
other  children.  This  case  stands  alone  in  the  literature  of 
orthopedic  surgery.  Most  of  the  results  obtained  by  oper- 
ative measures  are  not  worthy  of  comparison  with  it ;  and  no 
other  case,  so  far  as  the  writer  knows,  has  ever  been  reported 
where  so  successful  a  result  was  obtained  by  mechanical 
means.  In  such  treatment,  of  course,  the  first  matter  must 
be  to  draw  the  head  of  the  femur  into  place  by  continuous 
traction  made  upon  the  leg.  This  is  not  so  easy  a  matter 
as  it  would  seem,  and  is  often  accomplished  only  by  pro- 
longed and  continuous  traction.  Then  by  passive  move- 
ments, as  in  the  case  of  Dr.  Brown,  it  may  be  hoped  that  at 
the  site  of  the  old  acetabulum  a  lodgment  of  the  head  of 
the  femur  may  be  effected  ;  and  this  can  only  be  accomplished 
by  continued  movements  of  the  femur  after  it  has  been  re- 
duced to  its  proper  place. 

It  is  very  undesirable  to  begin  on  a  treatment  of  this  sort 
unless  there  is  a  prospect  that  it  can  be  carried  out  to  the 
end,  because  simply  to  stretch  the  connections  between  the 
femur  and  the  pelvis,  without  being  able  to  retain  the  femur 
in  its  new  position,  is  simply  to  make  the  limb  worse,  and 
the  patient's  condition  more  unfortunate  than  it  w^as  before. 
An  apparatus  is  described  by  Dr.  Bradford  which  has  as  its 
aim  the  maintenance  of  continuous  traction  without  such 
prolonged  recumbency  as  in  the  case  of  Dr.  Brown,  which 
consists  of  a  leather  jacket  to  which  rods  are  attached  at 
right  angles,  from  which  traction  is  made  upon  the  flexed 
joints,  so  that  the  child  mav  be  kept  on  a  frame  or  sitting  up 
without  loosing  the  traction  force.  The  writer  has  had  no 
personal  experience  with  the  method,  but  it  seems  to  offer 
certain  advantages  over  the  treatment  by  continued  recum- 
bency.  ■ 

The  use  of  corsets  and  pelvic  bands,  which  have  as  their 
object  the  retention  of  the  head  of  the  femur  in  its  proper 
place,  has  been,  largely  advocated,  especially  by  German 
writers.     Konig*   and    Landererf   use   corsets  of  felt,   sili- 

■^  Lelirbuch  d.  Spec.   Chir.,  1S87,  i'i.  p.  287.  i^  Archiv  f.  Kl.  Chir.,  18S5,  xxxii.  p.  516. 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  1 99 

cate,  or  plaster,  which,  they  think,  retain  the  head  of  the 
femur  in  place  and  improve  the  walk.  In  one  of  Landerer's 
cases  shortening  was  reduced  from  two  inches  to  two-thirds 
of  an  inch.  Motta  suspends  the  patient  by  the  head  and 
axillse,  and  takes  a  plaster  cast  of  the  affected  side,  while 
the  limb  is  pulled  down  as  far  as  possible  into  place.  From 
this  he  makes  a  poroplastic  splint,  which  is  worn  by  day  ; 
and  at  night  he  uses  a  gaiter  and  extension.  He  advocates 
the  method  as  "giving  an  immediate  correction,  or  at  least 
a  decided  lessening,  of  the  limp";  but  from  Landerer's 
corset  he  could  not  get  any  good  results.* 

Volkmann's  pupil,  Martin,  published  the  results  of  his 
master's  experience  with  hip  dislocation  in  the  course  of 
twenty-five  years  ;  and  the  best  that  could  be  said  was  that 
in  unilateral  dislocation  the  results  were  partly  satisfactory.! 

The  method  brought  forward  by  Paci,  of  Pisa,:]:  has  re- 
cently attracted  attention  as  a  means  of  reducing  congenital 
dislocation  of  the  hip.  It  has  as  its  object  a  series  of  manip- 
ulations to  cause  the  descent  of  the  head  of  the  femur  to  a 
place  near  where  the  acetabulum  should  be,  and,  if  such 
an  acetabulum  exists,  to  cause  a  reduction  of  the  disloca- 
tion. It  is  claimed  for  this  by  Redard  §  that  a  better  posi- 
tion may  be  obtained  by  affording  a  solid  bony  support  to 
the  head  of  the  femur  upon  the  ilium,  which  may  result  in 
the  formation  of  a  new  joint.  The  obstacle  to  reduction  is 
found  in  the  pelvitrochanteric  muscles  and  those  of  the 
thigh  and  leg.  The  first  attempt  is  to  cause  relaxation  of 
these  muscles  by  effecting  leverage  upon  the  dislocated 
bone.  This  method  consists  of  four  steps.  With  the 
patient  held  firmly  and  the  pelvis  fixed,  flexion  of  the  leg 
to  the  full  extent  should  be  accomplished.  This  causes  the 
descent  of  the  head  of  the  femur  as  far  as  possible.  Next 
a  slight  amount  of  abduction  is  made,  which  is  designed  to 

*Giorn.  della  R.  Accad.  di  Torino,  1886,  xxxiv.  p.  675. 

t  Deutsch.  Med.  Wchsft.,  1889,  No.  xvi.  +  Quoted  by  Redard. 

§  Archives  for  Ped.  (abst.),  March,  1891. 


200  DISEASES    OF    THE    HIP   JOINT 

place  the  head  anterior  to  the  acetabulum,  if  the  descent 
has  been  complete,  or  against  its  posterior  border,  if  the 
descent  has  been  incomplete.  In  the  third  step,  while 
abduction  is  maintained,  slow  external  rotation  is  effected, 
which  brings  the  head  of  the  femur  still  more  forward. 
Finally,  and  lastly,  the  thigh  is  slowly  extended,  one  hand 
pressed  upon  the  knee,  while  the  other  holds  the  foot  and 
leg,  the  whole  limb  being  turned  outward.  After  a  moder- 
ate degree  of  force  has  been  used,  the  contraction  generally 
yields  ;  and  the  thigh  can  be  completely  extended  in  general. 
It  is  said  that  ansesthesia  is  not  generally  necessary  for  this 
manipulation.  It  is  directed  that  the  limb  should  be  kept 
in  an  immovable  apparatus  for  a  month,  and  that  extension 
should  be  kept  up  for  three  months.  It  seems  impossible  to 
believe  that  so  serious  a  deformity  can  be  corrected  by  so 
simple  and  rapid  a  treatment. 

Some  years  ago  Dr.  Post,  of  Boston,  *  treated  a  case  of 
single  congenital  dislocation  of  the  hip  in  a  young  child 
by  etherizing  it,  and  pulling  the  head  of  the  femur  into 
normal  position  (in  this  case  there  was  an  acetabulum), 
and  retaining  it  there  by  a  plaster  of,  Paris  bandage  worn 
for  a  year.  In  discussing  the  various  methods  advocated 
for  the  reduction  of  hip  dislocations  by  mechanical  meas- 
ures, it  is  difficult  to  judge  their  merits  correctly.  The 
case  of  Dr.  Brown  was  perfectly  successful.  In  the  case 
of  the  method  advocated  by  Redard  and  others,  it  is 
doubtful  if  the  results  were  equally  good.  With  the  atten- 
tion paid  to  mechanical  orthopedics  in  America,  it  would 
seem  as  if  there  were  a  future  for  the  treatment  by 
extension  properly  carried  out.  In  a  personal  case  of  the 
writer's  recently  under  treatment,  a  girl  of  thirteen  with 
single  .dislocation  was  very  much  benefited  by  six  months' 
extension  in  bed,  and  after  that  wearing  a  protection  splint. 
The  limb  was  lengthened  nearly  an  inch ;  and  the  gain  has 
been  held,  although  it  is  too  early  to  judge  of  the  case,  only 

*  Quoted  by  Bradford  and  Lovett,  p.  519. 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  20I 

a  year  and  a  half  having  elapsed  since  the  beginning  of  treat- 
ment. The  success  of  mechanical  treatment  would  often 
seem  to  justify  the  undertaking  of  a  course  of  traction  treat- 
ment in  the  case  of  careful  and  faithful  parents.  The  child 
should  be  first  subjected  to  continuous  and  prolonged  exten- 
sion in  both  the  extended  position  and  with  the  thigh  flexed 
at  a  right  angle  to  the  body,  in  order  to  loosen  up  the  con- 
tracted muscles  and  ligaments,  due  to  the  abnormal  position 
of  the  femur.  This  may  be  accomplished — although  hardly 
so  well  —  by  the  use  of  the  long  traction  splint.  After 
that  it  would  seem  advisable  that  the  head  of  the  bone 
should  be  manipulated  in  this  new  position,  in  the  hope  of 
establishing  a  new  connection  for  it.  Then  walking  might 
be  attempted  very  gradually,  with  the  joint  protected  ;  and 
the  discontinuance  of  apparatus  should  only  be  considered 
after  the  lapse  of  a  great  many  months,  as  the  mechanical 
conditions  are  obviously  not  favorable  for  the  maintenance 
of  the  new  condition.  The  writer  has  had  no  personal  ex- 
perience with  the  method  advocated  by  Redard,  and  is  not 
competent  to  speak  of  its  merits. 

Operative  Treatment. 

The  treatment  of  congenital  dislocation  of  the  hip  by 
operation  apparently  dates  from  the  time  of  Guerin,*  who 
believed  that  the  cause  of  all  congenital  deformities  lay  in 
a  primary  muscular  contraction,  and  practised  tenotomy  of 
the  peritrochanteric  muscles  for  the  relief  of  this  dislocation. 
Later  he  realized  that  there  was  present,  also,  an  abnormality 
of  the  acetabulum  ;  and  he  added  to  his  tenotomy  subcutane- 
ous cuts  of  the  capsule,  and,  following  it,  progressive  move- 
ments of  the  limb,  hoping  to  obtain  the  formation  of  a  new 
articular  surface.  And,  to  aid  in  this,  he  used  also  prolonged 
extension.  This  method  was  tried  in  three  cases  of  uni- 
lateral  dislocation,   and    in   one  where   both    hips   were   in- 

*  Jules  Guerin,  Recherches  sur  les  Luxations  Congenitales.     1S41. 


202  DISEASES    OF    THE    HIP    JOINT 

volved.  Two  years  later  a  commission  of  the  Academy  of 
Medicine,  examining  these  cases,  reported  that  two  cases 
of  the  dislocation  were  not  cured,  but  that  a  lengthening  of 
two  centimetres  had  been  obtained.  The  treatment  of  the 
third  dislocation  had  been  temporarily  given  up,  and  the 
double  dislocation  was  not  far  enough  advanced  for  the  re- 
port. This  method  is  of  significance,  inasmuch  as  it  has 
been  the  basis  of  similar  operations  largely  practised  since. 

Bouvier  *  performed  subcutaneous  tenotomy  of  the  ad- 
ductors and  of  the  psoas  on  both  sides.  This  was  followed 
by  an  apparatus  which  held  the  limbs  abducted.  Some 
benefit  followed  the  operation.  Pravaz,  junior,!  performed 
a  subcutaneous  section  of  the  fascia  lata.  Corridge  i:  em- 
ployed tenotoni}'  and  continuous  extension  in  i860.  Brod- 
hurst,§  in  1865,  performed  a  subcutaneous  tenotomy  of  the 
contracted  muscles  in  the  case  of  a  child  twelve  years  old, 
who  had  not  been  benefited  by  continuous  extension  em- 
ployed for  some  months.  It  is  reported  that  at  the  end  of 
a  year  the  patient  walked  with  scarcely  a  limp.  A  second 
case  was  operated  upon  by  Brodhurst  ;  and  it  is  said  that 
six  months  after  operation  the  patient  walked  without  appa- 
ratus, and  that  the  head  of  the  femur  was  in  place.  Brod- 
hurst apparently  performed  a  third  operation,  which  he 
alluded  to  in  a  discussion  with  Bennett. || 

An  entirely  different  line  of  operation  was  undertaken  by 
Mayer,^  in  1845,  which  has  never  been  repeated,  for  obvi- 
ous reasons,  by  any  other  surgeon.  It  deserves  mention  on 
account  of  its  uniqueness.  In  a  case  of  unilateral  disloca- 
tion an  osteotomy  of  the  unaffected  leg  was  done,  in  order 
to  shorten  it,  and  thus  lessen  the  limp. 

Barwell  **  claims  to  have  obtained  two  good  results  by  the 
old    operation  of    Guerin.     He   performed  in  these  cases  a 

*  Lecons  Cliniques  sur  les  Mai  de  I'App.  Locoraoteur.     Paris,  1855. 

t  Union  Medicale,  1869.  J  Quoted  by  Giraldes,  Union  Med.,  1869. 

§  Lect.  on  Orth.  Surg.     London,  1S76.  ||  Lancet,  1S85,  i.  p.  271. 

UA.  Mayer,  Das  Neue  Heilverfahr.   bei  Fotalluxationen  durch  Osteotomie.     Wiirzburg,  1S55. 

**  British  Medical  Journal,  May  2S,  18S7. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT  203 

subcutaneous  tenotomy,  making  section  as  close  to  the  bone 
as  possible.  Continuous  extension  was  then  maintained  for 
some  weeks.  The  cases,  however,  were  reported  too  soon 
after  operation  to  be  of  any  great  value. 

Hueter  *  proposed  an  operation  which,  so  far  as  the  writer 
knows,  has  never  been  performed.  It  was  to  free  and  re- 
sect the  head  of  the  affected  femur,  and  then,  making  perios- 
teal flaps  from  the  neck  of  the  femur,  to  sew  them  to  perios- 
teal flaps  made  from  the  ilium,  thinking  thus  to  obtain  an 
osseous  union  between  the  pelvis  and  the  femur.  The  ex- 
treme difflculty  of  the  technique  would  make  the  operation 
seem  impracticable. 

Konigf  performed  a  similar  operation,  however.  He 
made  an  incision  exposing  the  posterior  part  of  the  acetabu- 
lum and  the  neighboring  part  of  the  iliac  bone.  Then,  incis- 
ing the  periosteum  in  a  curved  line  parallel  to  the  border  of 
the  acetabulum,  a  flap  of  periosteum  was  detached  from  the 
ilium,  running  from  this  incision  to  the  articulation,  thus 
being  attached  to  the  bone  only  at  the  border  of  the  cavity. 
It  was  twisted  so  that  the  articular  head  was  completely 
covered  by  it,  and  a  series  of  sutures  attached  it  to  the  cap- 
sule. Unfortunately,  the  child  died  of  scarlet  fever,  so  that 
the  results  of  the  operation  cannot  be  stated. 

De  Paoli  $  shaved  down  the  head  of  the  femur,  and,  having 
enlarged  the  acetabulum,  he  nailed  the  femur  in  place.  The 
result  was  so  bad  that  he  abandoned  the  operation  in  favor  of 
resection. 

Resection  of  the  Head  of  the  Femur. 

Resection  of  the  head  of  the  femur  is  a  proceeding  which 
is  open  to  two  objections.  In  the  first  place,  a  stiff  joint 
is  very  likely  to  result;  and  in  the  second  place  a  certain 
amount  of  shortening  is  necessitated  by  a  removal  of  part  of 
the  epiphysis  of  the  femur  in  a  growing  child,  as  well  as  by 

*  Klinik  der  Gelenkkrankbeiten.     1S70.  t  Lehrbuch  d.  Spec.  Chir.,  iSSg,  iii. 

+  Cent.  f.  Chir.j  1877,  p.  336. 


204  DISEASES    OF    THE    HIP    JOINT 

the  amount  of  bone  actually  removed.  Nevertheless,  the 
operation  has  been  largely  performed,  almost  entirely,  how- 
ever, by  continental  surgeons.  It  was  apparently  done  first 
by  Edmund  Rose,*  in  1874,  for  a  unilateral  dislocation  ;  and 
the  result  of  the  operation  is  not  on  record. 

Reyher  f  removed  the  head  of  the  femur  in  two  cases  of 
congenital  dislocation.  He  refreshed  the  surface  of  the  ace- 
tabulum, and,  replacing  the  neck  of  the  femur,  immobilized 
the  articulation.  In  two  cases  operated  upon,  at  the  end  of 
three  months  the  patients  were  able  to  walk. 

Margary  ^  at  first  attempted  a  proceeding  similar  to  that 
of  Hueter.  In  the  hope  of  improving  on  the  simple  opera- 
tion of  resection,  he  chiselled  an  acetabulum  where  it  should 
have  been  found,  and,  replacing  the  head  of  the  femur  in 
it,  he  made  a  capsule  of  periosteum.  The  patient  died  of 
pyaemia  after  operation,  which  was  attributable  to  septic  cat- 
gut. Since  that  time  Margary  has  become  a  warm  advocate 
of  excision  of  the  head  of  the  femur,  which  he  would  practise 
systematically  as  a  routine  treatment  in  dislocations  of  the 
hip.  He  has  reported  six  cases,  three  of  unilateral  disloca- 
tion and  three  of  double.  In  all  the  cases  but  one,  the  dif- 
ference in  length  of  the  limb  was  corrected.  With  regard  to 
the  ultimate  results,  one  of  the  patients  is  said  to  have 
walked  well,  one  walks  well  with  two  canes,  one  limps  even 
with  two  canes,  one  walks  badly  using  two  canes,  one  is  re- 
corded simply  as  limping,  and  the  condition  of  one  is  not 
stated.  Even  before  Margary  presented  his  cases  to  the  In- 
ternational Congress  at  Copenhagen,  the  operation  had  been 
performed  in  Germany  by  Heussner,  Schuessler,  and  Luecke. 
In  Heussner's  case  §  a  girl  of  twenty  was  operated  upon,  who 
had  suffered  very  much  in  walking.  The  head  and  neck  of 
the  f-emur  were  excised,  and  the  acetabulum  was  deepened. 
The  result  as  shown  by  Heussner,  in  1884,  was  that  the  girl 

*  Quoted  by  Kronlein  (Deutsche  Chir.).  t  Cent.  f.  Chir.,  1S84,  No.  14. 

t  Archivio  di  Ortopedia,  Anno  i.,  fasc.  5,  6. 

§  Arch.  f.  Klin.  Chir.,  xxx.  666,  and  Cent.  f.  Chir.,  1884,  No.  45. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT  205 

could  walk  for  half  an  hour  with  the  aid  of  a  cane  without 
fatigue.  The  dislocation  was  a  double  one,  and  ultimately 
the  patient  was  resected  upon  the  other  side  as  well.  Yet 
she  was  finally  obliged  to  undergo  ovariotomy,  after  which 
the  pain  subsided. 

In  the  case  of  Schuessler,*  it  was  a  unilateral  disloca- 
tion in  a  girl  sixteen  years  old.  Six  months  after  operation 
the  femur  was  firmly  in  its  new  cavity,  and  could  not  be  dis- 
placed upward.  The  leg  could  be  flexed  through  an  arc  of  40 
degrees,  and  abduction  of  8  degrees  could  be  made,  while  ro- 
tation was  fairly  free.  The  leg  was  5  centimetres  short,  and 
the  walk  was  decidedly  limping.  Two  years  and  a  half  after 
operation  the  patient  could  walk  without  a  cane,  and  the  tro- 
chanter was  5  centimetres  above  Nelaton's  line.  It  is  only 
necessary  to  add  the  comment  as  to  the  success  of  the  opera- 
tion that  before  excision  the  trochanter  was  only  6  centi- 
metres above  Nelaton's  line. 

In  the  case  of  Luecke,  f  the  patient  was  a  boy  of  fourteen, 
the  subject  of  various  malformations  besides  the  unilateral 
dislocation  of  the  hip.  The  ordinary  operation  was  per- 
formed, and  a  year  and  a  half  after  operation  the  patient 
could  walk  a  couple  of  hours  without  fatigue,  and  a  new  artic- 
ulation was  said  to  have  been  formed,  which  did  not  permit 
the  displacement  of  the  trochanter  upward. 

Lampugnani,  J  a  pupil  of  Margary,  has  reported  two  cases 
of  resection  of  the  hip.  In  one,  an  excision  was  performed 
by  the  Langenbeck  incision,  with  removal  of  the  head  of  the 
femur.  The  patient  was  four  months  in  an  extension  appa- 
ratus, and  finally  had  a  corset  applied.  Seven  months  after 
operation  the  extremity  of  the  femur  could  be  displaced 
upward  and  backward.  There  was  some  limping  present, 
and  the  trochanter  was  still  5  centimetres  above  Nelaton's 
line,    originally   having   been    only    8    centimetres.       Move- 

*  Berl.  Klin.  Wchsft.,  1887,  xxiv.  398. 

t  Quoted  by  Teufel,  Deutsche  Zeitsch.  f.  Chir.,  xxix.  343. 

+  Giornale  della  R.  Accad.  di  Med.  di  Torino,  fasc.  6,  7,  1S85. 


206  DISEASES    OF    THE    HIP    JOINT 

ment  at  the  joint  is  said  to  have  been  fair.  In  a  second 
operation  he  modified  the  proceeding  by  removing  the 
head  of  the  femur  obliquely,  so  that  the  upper  half  of  the 
head  would  be  the  part  to  come  in  contact  with  the  upper 
part  of  the  acetabulum.  The  patient  was  a  girl  twenty  years 
old,  and  the  trochanter  was  lo  centimetres  above  Nelaton's 
line.  The  head  of  the  femur  was  removed  obliquely  from  the 
point  of  insertion  of  the  round  ligament  to  the  limit  of  the 
neck  and  the  head,  so  that  the  upper  half  of  the  head  re- 
mained in  place.  In  an  examination  nine  months  after 
operation,  the  legs  were  found  to  be  of  equal  length,  the  tro- 
chanter was  only  5  centimetres  above  Nelaton's  line,  and 
the  movements  of  the  joint  possible  to  a  moderate  extent, 
but  were  accompanied  by  creaking. 

Motta,  *  another  pupil  of  Margary,  has  reported  two  cases 
of  excision  for  congenital  dislocation  in  children  six  and  nine 
years  old.  After  excision  he  treated  the  cases  by  extension 
in  a  position  of  abduction  and  outward  rotation.  This  was 
maintained  even  after  the  patients  were  allowed  to  go  about 
in  an  immovable  plaster  splint.  One  case  was  able  to  walk 
indefinitely  without  fatigue,  and  the  shortening  of  the  limb 
was  compensated  by  the  obliquity  of  the  pelvis. 

Raffo  t  is  reported  to  have  resected  a  case  with  much  im- 
provement in  the  walk.  Battini  f  has  resected  one  case  of 
unilateral  dislocation  and  two  of  double  dislocation,  with 
very  bad  results. 

De  Paoli  :|:  has  modified  the  simple  excision  by  nailing  the 
head  of  the  femur  to  the  pelvis  by  a  nail  driven  through  the 
trochanter  into  the  acetabulum.  A  good  result  was  obtained 
in  a  case  where  a  shortening  of  three  inches  had  existed,  but 
an  alarming  amount  of  fever  and  reaction  accompanied  the 
operation. 

MoUiere  §  has  reported  two  cases  operated  by  the  method 

*  Archivio  di  Ortopedia,  ii.  Nos.  3,  4,  and  5. 

t  Quoted  by  Ho£Ea,  Revue  d'Orth.,  March,  1891,  p.  loi.         +  Cent.  f.  Chin,  1877,  p.  336. 

§  Quoted  by  Porto,  Les  Lux.  Congen.  de  la  Hanche,  etc.     Paris,  18S7. 


CONGENITAL    DISLOCATION    OF    THE    HIP   JOINT  20/ 

of  Margary.  One,  a  girl  twelve  years  old,  with  unilateral  dis- 
location, was  resected  by  the  usual  method,  and  was  confined 
to  bed  only  two  months.  After  that  time  she  began  to  walk, 
and  the  length  of  the  legs  was  shown  by  measurement  to  be 
equal :  the  trochanter  of  the  right  side,  however,  was  4  cen- 
timetres higher  than  the  well  side.  Three  months  later  the 
patient  was  improving  in  her  walk  from  day  to  day.  In  a 
second  case,  a  girl  fourteen  years  old  had  double  congenital 
dislocation  of  the  hip.  Resection  of  the  right  side  was  done 
in  the  usual  way,  and  in  six  weeks  the  patient  is  reported  as 
walking  without  pain.  Two  months  later  the  other  hip  was 
resected,  and  at  the  end  of  a  month  the  patient  walked  with 
the  aid  of  a  cane.  Some  months  after  the  last  operation  the 
patient  was  still  progressing  favorably. 

Postempski  *  reports  a  very  good  result  due  to  resection. 
Ogston  t  has  operated  twice  for  dislocation  of  the  hip  by  re- 
section. In  one  case,  a  young  man  was  operated  on  on  both 
sides,  and  the  result  is  reported  as  an  improvement  one  year 
after  operation.  The  second  patient  was  less  satisfactory, 
and  complained  of  weakness  in  the  operated  limb. 

In  France,  Vincent  J  resected  a  hip  for  congenital  disloca- 
tion by  the  method  of  Oilier.  The  result  at  the  end  of  two 
years  was  a  fibrous  anchylosis,  which  permitted  walking  with 
much  less  pain  and  fatigue. 

One  finds,  therefore,  27  cases  of  reported  resection  for 
congenital  dislocation  of  the  hip,  17  of  which  were  unilateral 
and  7  bilateral,  leaving  3  cases  in  which  it  was  not  stated. 
In  the  7  cases  of  double  dislocation  the  results  were  not  alto- 
gether satisfactory.  Of  these  7,  3  walked  badly  after  opera- 
tion in  spite  of  the  support  of  crutches,  4  walked  passably, 
but  required  the  use  of  a  cane.  Displacement  of  the  femur 
during  walking  persisted  in  the  3  cases  which  were  examined 
in  regard  to  this. 

In  unilateral  dislocation  the  results  are  but  little  better. 

*  Quoted  by  Hoffa,  loc.  cit.  t  Ogston,  Ann.  of  Surgery,  viii.  p.  i. 

+  Brit.  Med.  Journal,  1885,  116. 


208 


DISEASES    OF    THE    HIP    fOINT 


In  1 6  cases  of  the  17  operated  upon,  one  was  able  to  walk 
all  day  without  fatigue  (^lotta),  2  could  walk  for  a  time  not 
exceeding  an  hour  and  a  half,  5  presented  an  improvement 
in  the  walk  in  general,  2  were  obliged  to  use  crutches,  6 
limped,  while  i  walked  worse  than  before  operation  (Langen- 
beck,  Battini). 

These  might  be  classed  3  good  results,  5  moderate  results, 
and  8  bad  ones.  The  defective  walk,  as  Hoffa  points  out,  is 
due  largely  to  the  shortening  produced  by  resection  ;  and  it 
is  to  be  expected  that  in  certain  of  these  cases  shortening 
will  ultimately  appear  in  the  operated  leg,  as  the  result  of 
the  injury  done  to  the  epiphysis  of  the  femur. 

It  therefore  seems  safe  to  say  with  regard  to  resection  of 
the  femur  as  a  curative  measure  in  congenital  dislocation 
of  the  hip  that  the  results  are  far  from  satisfactory.  In 
double  dislocation  the  results  are  notably  bad  in  many  cases  ; 
and  in  the  best  cases  they  are  not  worthy  of  comparison  with 
such  a  case,  for  instance,  as  that  reported  by  Dr.  Brown. 

In  unilateral  dislocation  the  results  are  somewhat  better ; 
but  the  details  of  the  cases  as  presented  by  the  reporters 
are  not  altogether  satisfactory,  and  a  large  proportion,  as  has 
been  seen,  are  failures,  so  that  even  in  these  cases  the  oper- 
ation is  to  be  regarded  as  a  measure  of  doubtful  utility. 

Cases  of  Resection  already  alluded  to. 


Rose,      .... 

.     I  case. 

Raffo,     .     .     . 

.     I  case. 

Reyher,  .... 

.     2  cases. 

Battini,   .     .     . 

.     3  cases 

Margary,     .     .     . 

.     6  cases. 

De  Paoli,    .     . 

.     I  case. 

Heussner,  .     .     . 

I  case. 

Postempski,    . 

I  case. 

Schuessler,      .     . 

.     T  case. 

Ogston,       .     . 

.     2  cases 

Luecke,  .... 

I  case. 

Vincent,      .     . 

.     I  case. 

Lampugnani, 

.     2  cases. 

MoUiere,     .     . 

.     2  cases 

Motta,    .... 

.     2  cases. 

CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  209 

Hoffa  s  Operation. 

Hoffa,*  who  believes  firmly  that  the  obstacle  to  reduction 
consists  more  in  contraction  of  the  periarticular  soft  parts 
than  in  any  bony  condition,  has  modified  the  operation  to 
combat  what  he  believes  to  be  the  source  of  failure.  He 
operates  by  a  free  incision  of  all  the  soft  parts  which  oppose 
reduction,  following  the  example  of  Lorenz.  In  cases  oper- 
ated upon  by  this  method  he  reports  a  practical  success 
enough  to  justify  his  theory.  The  essential  point  is  the  sec- 
tion of  the  soft  parts  all  around  the  great  trochanter,  which 
permits  the  replacement  of  the  head  in  the  acetabulum, 
which  can  easily  be  made  of  the  proper  size  to  receive  the 
head  of  the  femur.  The  operation  is,  in  a  word,  to  cut  down 
on  the  joint,  extirpate  the  capsule,  enlarge  the  acetabulum 
by  a  heavy  curette,  and  then  reduce  the  dislocation  by  the 
ordinary  manipulation.  A  tight  plaster  dressing  is  then 
applied  to  the  thorax  and  leg.  Dr.  Hoffa  has  recently  in- 
formed the  writer  that  he  has  already  operated  upon  several 
more  cases  successfully.  He  reports  7  cases  operated  upon 
by  this  method :  Case  one,  double  congenital  dislocation  in 
a  girl  two  years  and  a  half  old.  The  operation  was  done  by 
the  Langenbeck  incision,  and  at  first  without  division  of  all 
the  soft  parts.  It  was  impossible  to  make  the  head  of  the 
femur  descend  more  than  a  centimetre  and  a  half.  However, 
when  subperiosteal  division  was  made  of  the  muscular  inser- 
tions into  the  great  trochanter,  it  was  easy  to  make  the  head 
of  the  femur  descend  as  far  as  the  acetabulum.  The  acetabu- 
lum was  slightly  enlarged  and  the  head  of  the  femur  was  re- 
placed, being  kept  there  by  strong  extension  in  an  abducted 
position;  and,  owing  to  the  free  division  of  the  parts,  it 
showed  no  disposition  to  leave  its  new  place.  A  slight  diffi- 
culty was  experienced  by  tension  of  the  anterior  soft  parts, 
which  was  corrected  by  a  transverse  incision  of  the  fascia  lata. 
The  flap,  which  had  been  detached  from  the  bottom  of  the 

*  Revue  d'Orthopedie,  March,  1S91. 


210  DISEASES    OF    THE    HIP    JOINT 

acetabulum,  was  turned  back  and  attached  to  the  head  of 
the  femur.  The  wound  was  sutured  as  usual  and  the  plaster 
bandage  applied,  fixing  the  limb  in  a  position  of  abduction. 
Sixteen  days  later  the  wound  was  healed,  and  the  head  was 
found  in  the  acetabulum  with  free  movement.  The  great 
trochanter,  moreover,  was  on  Nelaton's  line,  and  the  oper- 
ated leg  was  3  centimetres  longer  than  the  one  which  had  not 
been  touched.  The  patient  was  discharged  from  treatment 
two  months  and  a  half  after  operation  ;  and,  when  seen  five 
months  after  excision,  she  could  walk  all  day  without  any 
appliance.  The  characteristic  limp  had  disappeared  on  the 
operated  side,  and  the  great  trochanter  was  still  on  Nelaton's 
line.  Nine  months  after  operation  the  movement  in  the 
limb  was  perfect,  and  one  year  after  the  original  operation 
the  left  hip  was  operated  upon  with  the  same  success. 
Three  months  after  leaving  the  hospital,  the  child  was  seen 
walking  without  appliances,  there  Avas  no  lordosis,  and  the 
heads  of  the  femora  were  not  displaced.  In  short,  the  case 
may  be  considered,  so  far  as  it  has  been  reported,  as  a  com- 
plete success. 

The  second  case,  a  girl  a  year  and  a  half  old,  with  double 
dislocation,  was  operated  upon  as  in  the  former  case,  and 
both  hips  were  exposed  and  the  heads  of  both  femora  re- 
placed. The  two  limbs  were  kept  in  a  position  of  abduction 
for  a  month,  when  passive  motion  was  begun ;  and  two 
months  after  operation  the  patient  left  the  hospital  to  have 
massage  and  passive  movements  done  at  home.  When  seen 
three  months  after  operation,  the  patient  could  stand  without 
support  and  solidly,  the  lordosis  had  disappeared,  and  the 
trochanter  was  on  Xelaton's  line.  A  final  examination, 
made  nearly  a  year  after  operation,  showed  that  the  child 
could  walk  without  a  trace  of  limp,  and  she  used  no  support. 

The  third  case  was  a  boy,  four  years  old,  with  double  dis- 
location. The  patient  had  been  treated  for  a  year  by  the 
method  of  Landerer,  and  the  trochanter  was  6  centimetres 
above  Xelaton's  line.     The  operation  was  done  on   the  left 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  211 

side,  and  five  days  later  on  the  right  side.  The  patient  died 
of  the  influenza,  which  was  prevailing  at  that  time,  ten  days 
after  the  second  operation.  The  autopsy  showed  pneumonia, 
w  hich  was  the  cause  of  death.  The  heads  of  the  femora 
were  very  firmly  fixed  in  their  new  cavities,  and  a  certain 
effort  was  necessary  to  dislocate  them.  The  head  itself  had 
preserved  the  same  a  ppearance  it  presented  at  operation. 
Where  the  muscular  insertions  had  been  detached  from  the 
great  trochanter,  there  were  granulating  surfaces.  The  new 
cavity  was  round,  large,  and  deep,  and  admitted  the  first 
phalanx  of  the  thumb  entirely.  It  was  covered  with  carti- 
lage, except  in  a  place  at  the  bottom  where  the  round  liga- 
ment was  inserted.  The  muscular  insertions,  which  had 
been  detached  from  the  trochanter,  were  attached  to  it  en- 
tirely, but  a  little  higher  than  their  original  insertion.  In 
short,  the  condition  at  the  end  of  ten  days  showed  the  heads 
of  the  bones  in  place,  and  progress  being  made  toward  a  firm 
and  probably  useful  joint. 

The  fourth  case  v/as  a  girl,  nineteen  years  old,  with  double 
congenital  dislocation.  The  operation  was  done  on  the  two 
sides  at  an  interval  of  fifteen  days,  and  four  months  after 
operation  the  patient  could  walk  with  two  canes  without  a 
trace  of  limp.  The  heads  of  the  bones  were  solidly  in  their 
places  and  only  two  months'  recumbency  had  been  necessary 
to  obtain  this  result. 

The  fifth  case  was  a  girl,  two  years  old,  with  unilateral 
dislocation.  The  operation  was  successful,  and  the  child  left 
the  hospital  two  years  after  operation,  completely  cured. 
She  wore,  however,  a  Taylor's  splint,  in  order  to  prevent 
relapse. 

The  sixth  case  was  a  girl,  six  years  old,  with  unilateral  dis- 
location. She  left  the  hospital  two  months  after  operation, 
and  is  recorded  a  complete  cure. 

The  seventh  case  was  a  girl,  two  years  and  a  half  old,  with 
double  congenital  dislocation.  One  side  had  been  operated 
upon  successfully,  and  the  patient  had  been  discharged  at 
the  end  of  a  month.     The  other  leg  had  not  been  touched. 


212  DISEASES    OF    THE    HIP    JOINT 

It  is  obvious  that  this  series  of  results  is  far  superior  to 
any  set  of  cases  which  have  been  reported.  The  movements 
of  many  of  them  are  recorded  as  perfect,  the  limp  is  said  to 
have  disappeared,  and,  so  far  as  one  can  judge  from  the  mere 
record,  in  operative  cases  the  method  should  be  accounted 
as  a  wholly  successful  one.  Hoffa  believes  that  there  is  no 
fear  of  a  relapse  if  one  enlarges  the  cavity  enough,  to  which 
excavation  he  attaches  extreme  importance.  Once  having 
reduced  the  dislocation,  he  believes  that  there  is  little  danger 
of  the  head  of  the  femur  leaving  the  acetabulum,  and  with 
the  beginning  of  movements  the  head  adapts  itself  still 
better  to  the  cavity.  He  quotes  the  law  of  Julius  Wolff, 
which  is  that,  when  one  has  re-established  normal  relations 
between  the  bones,  after  static  laws,  nature  tends  to  re-estab- 
lish the  architecture  and  the  normal  forms.  The  objection 
to  the  operation  which  Hoffa  states  himself  is  that  in  cer- 
tain cases  no  trace  of  an  acetabulum  can  be  found.  This 
amounts  to  but  very  little,  because  it  would  be  very  easy  to 
raise  the  flap  of  the  periosteum  at  the  corresponding  place 
and  to  chisel  an  acetabulum,  as  Ogston  has  done  in  his  case. 
Certainly,  the  operation  is  so  simple  and  so  well  vouched  for 
that  one  would  be  justified  in  trying  it,  especially  in  unilat- 
eral cases. 

The  writer  regrets  to  state  that  he  has  no  personal  ex- 
perience in  the  operative  treatment  of  congenital  disloca- 
tion, and  is  merely  able  to  present  the  literature  of  the 
subject,  with  only  such  obvious  comments  as  may  be  made 
from  the  study  of  the  cases. 

It  is  a  difficult  matter  to  sum  up  the  results  of  this  discus- 
sion of  the  treatment  of  congenital  dislocation  of  the  hip. 
Mechanical  measures  are,  as  a  rule,  unsuccessful ;  and  only 
in  exceptional  cases  where  the  patient  is  under  perfect  con- 
trol can  they  be  advised,  and  only  then  when  an  almost  un- 
limited time  is  at  the  disposal  of  the  surgeon  and  patient, 
and  where  the  patient  can  be  under  control  to  the  end. 
These    cases  are,  of   course,  very  unusual.      On    the    other 


CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT  213 

hand,  the  operative  treatment,  as  a  rule,  has  given  unsatis- 
factory results ;  and  but  little  can  be  said  in  favor  of  tenot- 
omy as  practised  by  Guerin  and  Barwell. 

Resection  of  the  hip  is  obviously  a  measure  which  is  likely 
to  cause  a  stiff  joint,  which  must  cause  shortening  of  the 
limb,  and  which  in  a  certain  proportion  of  cases,  as  can  be 
seen  from  the  table  given  above,  ends  in  absolute  failure. 

With  regard  to  the  operation  of  Hoffa  it  must  be  said  that 
it  is  still  on  trial.  All  the  cases  which  have  been  reported 
are  comparatively  recent ;  and  in  spite  of  the  very  favorable 
showing  of  these  seven  cases,  until  the  conclusions  of  the 
originator  have  been  verified  by  the  profession  at  large,  it 
can  only  be  said  that  the  operation  should  be  considered  as 
being  on  trial,  and  one  of  much  promise. 

Paralytic  Dislocation  of  the  Hip. 

A  word  should  be  said  of  a  class  of  hip  dislocations  which 
simulate  congenital  dislocation  very  closely.  These  are  dis- 
locations due  to  an  anterior  poliomyelitis  which  has  destroyed 
the  muscular  tissue  and  weakened  the  ligaments  about  the 
hip,  so  that  a  flail-like  joint  may  result  by  this.  These 
joints  are  readily  amenable  to  orthopedic  treatment ;  but 
certain  of  these  patients  are  not  able  to  carry  this  out 
properly,  and  in  these  the  question  of  operation  comes 
forward. 

Karewski  *  has  operated  seven  times  in  cases  of  paralytic 
hip  dislocations  with  the  best  of  results.  An  operation 
similar  to  that  of  Hoffa  or  even  resection  would  seem  to 
be  indicated   in   these  cases. 

Recent  Literature  with  regard  to   Hip    Dislocation. 

Krause,  2  cases  of  catarrhal  inflammation  of  congenitally 
dislocated    joints;    Arch,    f,    Klin.    Chir.,   1889,  xxxix.  477; 

*  Quoted  by  Hoffa,  loc.  cit. 


214  DISEASES    OF    THE    HIP    JOINT 

Motta,  Arch,  di  Ortop.,  Milan,  1889,  vi.  304 ;  Adams,  Br.  'M.  J., 
London,  1890,  i.  406;  Clark,  Glas.  Med.  J.,  1890,  xxxiii.  102; 
Verneuil,  Rev.  d'Orth.,  Paris,  1890,  i.  23  ;  Dubreuil,  Rev. 
d'Orth.,  Paris,  1890,  i.  185;  Hoffa,  Wien.  Med.  Wchsft, 
1890,  xl.  926;  Poggi,  Arch,  di  Ortop.,  1890,  vii.  105; 
Rosenfeld,  Mtinch.  Med.  Wchsft,  1S90,  37,  415,  etc.;  Paci, 
Arch,  di  Ortop.,   1890,  vii.    151. 

The  rest  of  the  bibliography  has  practically  been  given  as 
references  in  the  course  of  the  section. 


HYSTERICAL    AFFECTIONS    OF    THE    HIP   JOINT  21$ 


Chapter    XIII. 
HYSTERICAL  AFFECTIONS  OF  THE   HIP  JOINT. 

Pathology. 

The  appearances  are  entirely  negative  except  for  pallor 
and  atrophy  of  the  muscles  of  the  diseased  leg,  occasioned 
by  disuse. 

Etiology. 

The  designation  of  the  diseases  of  this  class  as  hysterical 
is  more  or  less  unfortunate,  and  the  word  neuromisis,  or 
functional  affection,  is  perhaps  to  be  preferred.  The  dis- 
order is  not  to  be  regarded  as  imaginary,  but  is  due  to 
a  disordered  nervous  and  circulatory  condition,  the  charac- 
ter of  which  is  obscure,  and  the  evidences  of  which  are 
not  revealed  by  microscopic  examination.  The  term  func- 
tional merely  means  that  there  are  no  evidences  of  organic 
disease,  and  the  affection  is  one  of  such  practical  impor- 
tance that  its  etiology  and  treatment  deserve  consideration. 
Brodie  makes  the  assertion,  which  Esmarch  indorses,  "  I 
do  not  hesitate  to  declare  that  among  the  higher  classes 
of  society  at  least  four-fifths  of  the  female  patients,  who  are 
commonly  supposed  to  labor  under  disease  of  the  joints, 
labor  under  hysteria,  and  nothing  else."  Skey  added  that  this 
includes  a  large  proportion  of  the  lower  classes,  and  further  : 
"  In  reference  to  spinal  affections  in  young  persons,  I 
unhesitatingly  assert  that  the  real  disease  is  not  found  in 
a  greater  proportion  than  one  case  in  twenty,"  In  these 
statements  Shaffer  agrees,  believing  neuromimetic  joints 
are  exceedingly  frequent  both  in  the  upper  and  lower 
classes,  especially  at  that  age  when  hysteria  is  most  likely  to 


2l6  DISEASES    OF    THE    HIP    JOINT 

develop.  The  cause  of  the  manifestations  of  these  symp- 
toms is  obscure.  The  symptoms,  as  it  is  known,  simulate 
very  closely  those  of  the  real  disease,  even  in  persons  igno- 
rant of  the  symptoms  of  hip  disease. 

The  patients  are  for  the  most  part  young  girls  or  women 
who  are  not  robust,  as  a  rule.  Occasionally,  it  occurs  in 
connection  with  overgrowth,  and  not  uncommonly  at  the 
age  of  puberty.  In  older  women  it  is  likely  to  be  associated 
with  ovarian  tenderness  or  uterine  disorders.  It  is  not 
always  confined  to  persons  of  an  excitable,  emotional  tem- 
perament, but  it  is  sometimes  seen  in  persons  who  might  be 
considered  otherwise  phlegmatic.  It  is  rarely,  however,  that 
it  is  found  \vithout  some  other  symptoms  of  the  condition 
known  as  neurasthenia.  Most  often  there  is  associated  with 
it  a  nervous  condition,  with  either  backache,  tingling  of  the 
hands  and  feet,  tenderness  over  the  abdomen,  or  some  other 
sensory  disturbance. 

It  must  not  be  overlooked  that,  although,  for  the  most 
part,  these  affections  are  seen  in  young  women  at  or  shortly 
after  puberty  and  in  w^omen  at  the  time  of  menopause,  they 
occasionally  occur  in  young  children  and  in  young  men. 
Such  cases  are  not  common,  but  they  occur  frequently 
enough  to  deserve  mention. 

Perhaps  the  most  constant  accompaniment  of  the  condi- 
tion is  a  state  of  disability  and  ill  health,  perhaps  marked, 
perhaps  only  slight. 

Hysterical  disease  is  associated  in  a  large  proportion  of 
instances  with  a  fall  or  sprain.  In  these  cases,  it  seems  as  if 
an  acute  synovitis  had  occurred,  which  had  been  the  occa- 
sion of  real  pain,  and  that  on  account  of  some  circulatory 
disturbance  the  sensation  had  persisted  after  the  cause  for  it 
had  disappeared.  It  is  not  always  the  case  by  any  means 
that  these  cases  are  traumatic,  but  a  large  proportion  of 
them  show  this  clearly.  In  other  cases,  which  constitute  a 
still  more  difficult  class,  the  hysterical  symptoms  are  asso- 
ciated with  a  certain  amount  of  real  disease ;  that  is  to  say,  a 


HYSTERICAL    AFFECTIONS    OF    THE    HIP    JOINT  21 7 

slight  ostitis  of  the  hip  is  exaggerated  by  the  patient  into  a 
condition  of  excessive  sensitiveness,  so  that  it  resembles  the 
severest  hip  disease  that  one  would  see.  In  these  cases,  the 
affection  is  more  functional  than  real,  and  ostitis  is  to  be 
accounted  as  one  of  the  causes  of  functional  hip  disease. 

The  place  of  errors  of  refraction  of  the  eye  in  the  causa- 
tion of  hysterical  joint  manifestations  ought  not  to  be  over- 
looked. In  a  certain  proportion  of  cases  where  functional 
affections  of  the  spine  or  hip  exist,  a  myopia  or  an  astigma- 
tism may  be  found  to  exist,  which,  if  corrected  by  proper 
glasses,  will  aid  much  in  the  treatment  of  the  local  trouble. 

In  a  certain  proportion  of  cases,  however,  it  seems  impos- 
sible to  assign  any  reasonable  cause  for  the  hysterical  joint 
affection,  and  patients  may  be  in  what  appears  to  be  good 
health.  There  is  no  history  of  accident,  and  they  may  be 
no  more  emotional  and  excitable  than  the  average  woman ; 
but  the  hip  disease  may  nevertheless  have  occurred,  and 
these  cases  are  set  down  in  the  unsatisfactory  classification 
of  idiopathic. 

In  short,  apart  from  traumatism,  there  is  little  to  be  said 
about  the  etiology  of  hysterical  hip  disease  which  is  different 
from  the  etiology  of  the  hysterical  manifestations  in  general, 
as  they  affect  the  same  class  of  people  and  are  subject  to 
most  of  the  same  conditions. 


Treatment. 

It  is  exceedingly  difficult  to  lay  down  any  routine  treat- 
ment for  an  affection  which  manifests  itself  in  so  many  ways 
as  does  hysterical  hip  disease.  The  general  treatment  forms 
an  important  part,  perhaps  the  most  important  part  in  the 
whole.  The  general  condition  is  almost  always  below  what 
it  should  be,  and  the  morale  is  almost  invariably  at  fault. 
The  remedy  of  these  two  conditions  requires  all  the  sur- 
geon's skill,  and  often  for  its  conduct  a  knowledge  of  human 
nature. 


21 8  DISEASES    OF    THE    HIP    JOINT 

In  regard  to  the  general  condition,  a  good  plan  of  treat- 
ment is,  as  a  rule,  that  of  Weir  Mitchell.  It  consists  in  the 
free  nourishment  of  these  patients.  Even  where  confine- 
ment to  bed  and  isolation  are  not  necessary,  additional  meals 
and  overfeeding  with  easily  digested  substances  are  of  the 
greatest  possible  benefit.  These  rank  in  their  usefulness 
much  higher  than  the  use  of  any  medicine  ;  and  the  use  of 
drugs,  as  a  rule,  should  be  limited  to  tonics,  and  temporarily 
to  the  use  of  nervous  sedatives,  such  as  bromide  of  potash. 

With  regard  to  the  diseased  morale  of  the  patient,  it  must 
be  remembered  that  the  fault  lies  in  a  concentration  of  the 
attention  and  of  the  imagination  upon  the  affected  joint.  In 
directing  this  part  of  the  treatment,  it  is  absolutely  essential 
that  the  surgeon  should  be  sure  of  his  diagnosis.  Tempo- 
rizing has  no  place  in  the  treatment,  and  the  treatment  that 
would  be  proper  for  hip  disease  is  wrong  for  hysterical  dis- 
ease ;  and  no  middle  course  of  treatment  can  be  adopted 
which  will  cover  both  conditions. 

Consequently,  the  treatment  must  be  based  absolutely  on 
the  diagnosis,  of  which  the  surgeon  inust  be  sure.  Having 
assured  himself  that  there  is  no  organic  trouble  in  the  hip, 
the  problem  is  one  of  diverting  the  patient's  attention  from 
the  sensations  experienced  in  the  hip.  This  may  be  done  in 
one  of  two  ways  :  by  a  sudden  mental  impression,  such  as  is 
made  by  charlatans  and  faith-healers,  it  is  often  possible  to 
divert  the  attention,  for  instance,  by  a  sudden  command  to 
walk,  that  the  patient  finds  herself  accomplishing  movements 
which  she  had  for  a  long  time  supposed  herself  unable  to 
make.  It  is  in  these  cases  the  absorption  of  the  sensation 
in  a  stronger  emotion  ;  but  such  treatment  is  not,  as  a  rule, 
applicable  in  legitimate  medical  practice,  and  an  attempt  to 
carry  out  this  treatment  and  its  failure  would  be  obviously 
disastrous  to  the  future  conduct  of  the  case. 

With  regard  to  the  second  and  more  usual  method  of 
treatment :  this  may  be  said  to  consist  in  a  gradual  educa- 
tion of  the  patient  into  better  methods  of  thinking,  by  di- 


HYSTERICAL    AFFECTIONS    OF    THE    HIP   JOINT  2I9 

verting  the  attention  from  tlie  diseased  structure,  and  by 
gradually  conducting  tlie  patient  to  use  the  affected  limb 
without  regard  to  the  pain  experienced.  It  is  obvious  for 
this  reason,  as  has  been  said,  that  the  diagnosis  must  be  one 
which  can  be  relied  upon.  In  these  cases,  it  is  generally  ad- 
visable to  put  the  patient  to  bed  at  first,  with  perhaps  trac- 
tion made  in  the  line  of  deformity.  Then  either  with  or 
without  the  use  of  apparatus,  as  would  seem  best,  the  patient 
is  encouraged  to  walk,  perhaps  one  step ;  on  the  next  day 
perhaps  two  steps  may  be  accomplished,  and  by  gradual 
careful  increase  of  the  exercise  the  patient  is  led  into  the 
use  of  the  affected  limb,  without  always  perceiving  the  prog- 
ress which  is  being  made  at  every  step  in  the  treatment. 
The  surgeon's  own  personal  attention  is  almost  an  essen- 
tial to  the  rapid  and  successful  treatment  of  these  cases. 

The  problem  is,  as  has  been  stated,  simply  to  educate  the 
patient  unconsciously  into  the  use  of  the  affected  limb;  and, 
when  this  has  been  accomplished,  the  pain  is  less  complained 
of,  and  with  the  normal  use  of  the  hip  the  circulatory  condi- 
tions are  improved  and  the  local  trouble  is  diminished,  so 
that  the  patient  ceases  to  complain  of  pain,  and  the  normal 
function  seems  once  more  established.  Pain  must  be  disre- 
garded as  a  significant  symptom. 

It  is  not  possible  to  lay  down  the  use  of  any  one  apparatus 
for  these  cases.  In  some  cases,  a  traction  splint  or  a  protec- 
tion splint  may  be  indicated.  In  other  cases,  nothing  more 
than  crutches  may  be  necessary.  In  other  cases,  plasters 
and  electricity  may  be  applied,  whichever  will  appeal  more  to 
the  imagination  of  the  patient. 

One  grand  aim  of  the  treatment  is  to  impress  upon  the 
patient's  mind  the  fact  that  the  therapeutic  measures  em- 
ployed are  those  which  are  best  suited  to  her  individual 
case,  and,  as  a  rule,  to  use  those  which  will  make  the  strong. 
est  mental  impression.  In  other  cases,  mechanical,  passive 
and  active  exercises  by  Zander's  system  may  be  of  use. 


220  DISEASES  OF  THE  HIP  JOINT 

Gymnasium  exercises  of  a  simpler  character  for  the  af- 
fected limb  are  also  useful  when  the  function  has  been  par- 
tially restored,  on  account  of  the  muscular  atrophy  which 
has  accompanied  the  disease  of  the  limb,  which  gives  rise  to 
a  feeling  of  weakness.  Massage  often  is  of  much  use.  In 
short,  the  treatment  must  be  modified  to  suit  each  case, 
following  in  general  the  lines  laid  down  in  the  earlier  part  of 
this  section. 

One  word  should  be  said  as  to  the  absolute  necessity  of 
the  surgeon's  having  complete  control  of  the  patient.  Home 
influences  are  often  much  to  be  blamed  as  the  cause  of  the 
affection  ;  and  often  isolation  of  the  patient  is  necessary  as  a 
therapeutic  measure,  to  cut  her  off  from  the  ill-judged  sym- 
pathy of  friends  and  relatives. 


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